A patient with a history of hypertension arrives in the emergency department with a blood pressure (BP) reading of 213/126 mm Hg. The patient has a history of drug abuse.

Which of the following initial questions posed by the nurse is MOST appropriate?.

"Did you take any Tylenol today?".

"Have there been recent stressful events in your life?".

"Have you recently taken any cocaine or crack?".

"Have you eaten any salty foods lately?". .

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Tylenol, or acetaminophen, is a common over-the-counter medication used to reduce fevers and manage mild aches and pains. It does not directly affect blood pressure.

Choice B rationale:

While stress can cause temporary spikes in blood pressure, it’s not clear whether stress can cause long-term increases in blood pressure34.

Choice C rationale:

Cocaine or crack use can cause a significant and dangerous increase in blood pressure. Given the patient’s history of drug abuse and the current high blood pressure reading, this is a critical question to ask.

Choice D rationale:

Eating salty foods can contribute to high blood pressure over time, but it’s unlikely to cause an immediate severe increase in blood pressure.

So, the correct answer is Choice C, after analyzing all choices. .

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Correct Answer is B

Explanation

Choice A rationale:

A weight increase from 120 pounds to 122 pounds over 3 days is within the normal fluctuation range.

Choice B rationale:

A serum potassium level of 3.0 mEq/L after 1 week of therapy is concerning because it’s below the normal range (3.5-5.0 mEq/L)171819. This could indicate hypokalemia, which can cause serious complications if left untreated.

Choice C rationale:

A palpable liver edge 2 cm below the ribs on the right side could suggest an abnormality such as an enlarged liver.

Choice D rationale:

The presence of 1+ to 2+ edema in the feet and ankles could indicate conditions like heart failure or venous insufficiency.

So, the correct answer is Choice B, after analyzing all choices.

A. Apical pulse. B. Adolescent's position. C. Pulses of right extremity. D. Pain. E. Pressure dressing. F. Respiratory rate. G. Blood pressure. H. Temperature & appearance of right lower extremity.

Correct Answer is ["C","E","G","H"]

Explanation

Choice A rationale:

The apical pulse rate increased from 90/min to 112/min, which is still within the normal range (60-100 beats per minute). Therefore, it’s not a critical change.

Choice B rationale:

The adolescent’s position, supine with legs straight, is the recommended position after cardiac catheterization to prevent bleeding from the femoral artery puncture site.

Choice C rationale:

The pulses of the right extremity decreased to 2+, indicating reduced blood flow. This is a critical finding and should be reported.

Choice D rationale:

The pain increased from 0 to 2 on a scale of 0 to 10. While any increase in pain should be monitored, a score of 2 is not typically considered severe.

Choice E rationale:

The pressure dressing became saturated with bloody drainage, indicating possible bleeding. This is a critical finding and should be reported.

Choice F rationale:

The respiratory rate increased from 16/min to 18/min, which is still within the normal range (12-20 breaths per minute). Therefore, it’s not a critical change.

Choice G rationale:

The blood pressure decreased from 120/76 mm Hg to 100/52 mm Hg. A significant drop in blood pressure can indicate blood loss or shock. This is a critical finding and should be reported.

Choice H rationale:

The right lower extremity became cool and pale, indicating reduced blood flow. This is a critical finding and should be reported.

So, the correct answer is Choice C, E, G, H, after analyzing all choices. .

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A patient with a history of hypertension arrives in the emergency department with a blood pressure (BP) reading of 213/126 mm Hg. The patient has a history of drug abuse. Which of the following initial questions posed by the nurse is MOST appropriate?.

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A patient with a history of hypertension arrives in the emergency department with a blood pressure (BP) reading of 213/126 mm Hg. The patient has a history of drug abuse.

Which of the following initial questions posed by the nurse is MOST appropriate?.