The charge nurse observes a new registered nurse (RN) doing discharge teaching for a client with hypertension who has a new prescription for enalapril (Vasotec). Which statement of the nurse to the patient would require the charge nurse's intervention?
"Make an appointment with the dietitian for teaching.”
"Check your blood pressure at home at least once a day." C. "Increase your dietary intake of high-potassium foods.”
"Move slowly when moving from lying to sitting to standing.”
"Move slowly when moving from lying to sitting to standing.”
The Correct Answer is C
Enalapril (Vasotec) is an angiotensin-converting enzyme (ACE) inhibitor medication commonly used to treat hypertension. One of the potential side effects of ACE inhibitors is hyperkalemia, which is an elevated level of potassium in the blood. Therefore, it is generally recommended for patients taking ACE inhibitors to avoid excessive intake of high-potassium foods.
The charge nurse should intervene because advising the client to increase their dietary intake of high-potassium foods contradicts the precautions associated with taking enalapril. Consuming high-potassium foods while taking this medication can potentially lead to an increased risk of hyperkalemia, which can have serious health consequences.
Let's review the other statements made by the nurse:
"Make an appointment with the dietitian for teaching": This is an appropriate statement as it encourages the client to seek professional guidance on dietary management of hypertension. A dietitian can provide valuable information on healthy eating habits and strategies to reduce blood pressure.
"Check your blood pressure at home at least once a day": This is also an appropriate statement as it promotes self-monitoring of blood pressure, which is important for clients with hypertension. Regular monitoring helps the client track their progress and detect any changes that may require medical attention.
"Move slowly when moving from lying to sitting to standing": This is a correct statement as it advises the client to practice orthostatic precautions. ACE inhibitors, including enalapril, can cause orthostatic hypotension, a drop in blood pressure upon standing. Moving slowly can help prevent dizziness and falls.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Abdominal aortic aneurysms (AAA) often do not present with specific symptoms in the early stages. It is not uncommon for individuals with AAA to be asymptomatic or have vague symptoms. Therefore, the absence of abdominal pain or any problems related to the abdomen is a common finding during the assessment of a client with an abdominal aortic aneurysm.
Let's briefly review the other statements:
"I have stomach pain every time I eat a big, heavy meal": This statement is more suggestive of gastrointestinal issues such as indigestion or acid reflux rather than specifically related to an abdominal aortic aneurysm.
"I have periodic episodes of constipation and then diarrhea": This statement may indicate gastrointestinal issues, but it is not a typical symptom associated with an abdominal aortic aneurysm. AAA is primarily related to the aorta, the main blood vessel in the abdomen, and its symptoms are not directly linked to bowel function.
"I belch a lot, especially when I lay down after eating": This statement suggests gastrointestinal symptoms such as acid reflux or gastroesophageal reflux disease (GERD). While these symptoms may be unrelated to the abdominal aortic aneurysm itself, they can coexist with other conditions.
Correct Answer is D
Explanation
Hypertension, or high blood pressure, is often referred to as the "silent killer" because it typically does not cause noticeable symptoms until it has already caused damage to target organs such as the heart, blood vessels, kidneys, or brain. It is crucial for the client to understand that even if they do not experience symptoms, untreated or poorly controlled hypertension can lead to serious complications, including heart disease, stroke, kidney problems, and more.
While dietary changes and increasing physical activity are important lifestyle modifications for managing hypertension, it is not accurate to state that most people can control their blood pressure through these measures alone. Hypertension is a complex condition influenced by multiple factors, and many individuals require additional interventions, such as medication, to effectively manage their blood pressure.
Annual blood pressure checks are indeed important to monitor the effectiveness of treatment and ensure that blood pressure remains within the target range. However, this information is secondary to the understanding that hypertension is typically asymptomatic until target organ damage occurs.
Recognizing the potential risks associated with untreated or uncontrolled hypertension can motivate the client to adhere to their treatment plan and make necessary lifestyle changes.
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