The nurse is assessing a client who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider?

Tremors are noted in the fingers when the client extends the arms.

The client cannot move the left arm and leg when asked to do so.

Urine output over 8 hours is 250 mL less than the fluid intake.

The client reports a headache with pain at level 7 of 10 (0 to 10 scale).

Answer and Explanation

The Correct Answer is B

The most important finding to report to the healthcare provider in a client admitted to the intensive care unit (ICU) with a hypertensive emergency is option B, "The client cannot move the left arm and leg when asked to do so."

Hypertensive emergencies are critical situations where extremely high blood pressure levels can lead to damage or dysfunction in vital organs, such as the brain, heart, kidneys, and eyes. Neurological symptoms are particularly concerning in this context, as they may indicate acute brain injury or stroke resulting from uncontrolled high blood pressure.

Option A, "Tremors are noted in the fingers when the client extends the arms," could be concerning but is not as immediately critical as the neurological deficit described in option B. Tremors can have various causes and may not directly relate to the hypertensive emergency unless other signs or symptoms of neurologic impairment are also present.

Option C, "Urine output over 8 hours is 250 mL less than the fluid intake," is relevant to monitor the client's fluid status and kidney function, but it does not indicate an acute, life-threatening condition that requires immediate attention like the neurological deficit in option B.

Option D, "The client reports a headache with pain at level 7 of 10 (0 to 10 scale)," is concerning and may be a symptom of the hypertensive emergency, but it is not as urgent as the neurological findings. Headache can be a symptom of elevated blood pressure, but it is not sufficient on its own to determine the severity of the hypertensive crisis.

In a hypertensive emergency, the priority is to identify and manage potential complications, such as neurological deficits, acute organ damage, or signs of target organ dysfunction. Prompt reporting of any neurological changes is crucial, as it may prompt immediate interventions to prevent further neurological deterioration. The healthcare provider needs to assess the client's neurological status promptly and determine appropriate management to prevent further complications.

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Correct Answer is B

Explanation

Chronic kidney disease (CKD) is a condition where the kidneys are damaged or unable to filter blood effectively over time, leading to a gradual loss of kidney function. Several risk factors can increase the likelihood of developing CKD, and among them, diabetes and hypertension are the most common.

Diabetes is a significant risk factor for developing CKD. It can cause damage to the small blood vessels in the kidneys, impairing their ability to filter waste and fluid from the blood properly. Native Americans, along with other racial and ethnic minorities, are at a higher risk of developing diabetes compared to the general population.

While hypertension (high blood pressure) is also a risk factor for CKD, diabetes carries a higher risk. However, it's important to note that hypertension is often a comorbidity associated with CKD and can further worsen kidney function when present.

The other options listed (a 50-year-old white female with hypertension, a 40-year-old Hispanic female with cardiovascular disease, and a 28-year-old African American female with a urinary tract infection) are also at risk for CKD, but the 61-year-old Native American male with diabetes is at the highest risk based on the information provided. All patients should be educated about preventive measures to protect their kidney health, but special attention should be given to individuals with diabetes due to its significant impact on kidney function.

A. The client has had a 3 lb weight gain since yesterday. B. Flattened neck veins C. Oxygen saturation 93% D. Return of skin to previous position when the client's shin is palpated

Correct Answer is A

Explanation

A 3 lb weight gain in a short period, especially overnight, is indicative of fluid overload in a client with end-stage kidney disease receiving hemodialysis. Hemodialysis is performed to remove excess fluid and waste products from the body. If the client is experiencing fluid overload, it means that their body is retaining more fluid than it should, and this can lead to complications such as pulmonary edema, heart failure, and other cardiovascular problems. The nurse should identify this finding as an indication of potential fluid overload and report it to the healthcare provider for further evaluation and intervention.

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The nurse is assessing a client who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which patient is most likely to develop chronic kidney disease (CKD) and should be taught preventive measures by the nurse?

Correct Answer is B

Explanation

A nurse is assessing a client who has end-stage kidney disease and is receiving hemodialysis. Which of the following findings should the nurse identify as an indication the client is experiencing fluid overload?

Correct Answer is A

Explanation

Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown origin?

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The nurse is assessing a client who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider?

The nurse on the intermediate care unit received a change-of-shift report on four patients with hypertension. Which patient should the nurse assess first?

After receiving change-of-shift report on a heart failure unit, which client should the nurse assess first?

The assessment findings of a patient with myocardial infarction (MI) include jugular venous distention, weight gain, peripheral edema, and a heart rate of 108/minute. The nurse suspects what complication?

The nurse is reviewing the laboratory test results for a client who has recently been diagnosed with hypertension. Which result is most important to communicate to the health care provider?