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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Pericarditis is inflammation of the pericardium, the sac-like membrane surrounding the heart. It can cause chest pain, which is often worsened by deep breathing or coughing. The goal of treatment for pericarditis is to reduce inflammation and relieve pain.

In this case, the client's pain level is reported as 6 out of 10. As per the PRN (as-needed) medication options given:

C) Oral ibuprofen (Motrin) 600 mg: Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) and can help reduce inflammation and relieve pain in cases of pericarditis. It is an appropriate choice for this client's pain level of 6 out of 10.

A) IV morphine sulfate 4 mg: IV morphine is a potent opioid analgesic and may be appropriate for severe pain. However, in this case, the client's pain level is moderate (6 out of 10), and it is not the first-line medication for pericarditis pain.

B) Oral acetaminophen (Tylenol) 650 mg: Acetaminophen is a mild analgesic and antipyretic that can be effective for mild to moderate pain. However, in this situation, the client's pain is moderate (6 out of 10), and acetaminophen alone may not provide adequate relief for pericarditis pain.

D) Fentanyl 1 mg IV: Fentanyl is another potent opioid analgesic. However, similar to morphine, it may be more appropriate for severe pain, not moderate pain like in this scenario.

Based on the client's pain level and the goal of reducing inflammation, the most appropriate PRN medication for the nurse to give is oral ibuprofen (Motrin) 600 mg.

A. Heart rate 102 beats/min B. Report of chest pain C. Blood pressure 103/54 mm Hg D. Pedal pulses 1+ bilaterally

Correct Answer is C

Explanation

Among the given options, the assessment data that indicate the need for immediate action by the nurse is a blood pressure of 103/54 mm Hg. This blood pressure reading indicates hypotension, which can be concerning for a post-angioplasty patient.

Angioplasty with stent placement is an invasive procedure, and patients may experience fluctuations in blood pressure during the immediate post-operative period. Hypotension after angioplasty can be a sign of inadequate cardiac output, which may be due to issues like bleeding, fluid loss, or heart dysfunction. Inadequate blood pressure can lead to decreased perfusion to vital organs, including the heart itself, and can be life-threatening.

Options A, B, and D are also important to address:

A) Heart rate 102 beats/min: A heart rate of 102 beats per minute may indicate tachycardia, which can be expected after a procedure like angioplasty. However, it is not as urgent of a concern as hypotension, and it may be a normal compensatory response to the body's stress.

B) Report of chest pain: Chest pain after angioplasty can be common, but it should be evaluated further to ensure it is not indicative of complications such as coronary artery spasms, clot formation, or restenosis of the treated artery. While this is an important issue to address, it does not take precedence over hypotension.

D) Pedal pulses 1+ bilaterally: This finding suggests that the peripheral pulses in the feet are weak, and it could be related to the patient's medical condition, medications, or positioning. While it requires attention, it is not an immediate threat to the patient's life compared to severe hypotension.

Therefore, the nurse should prioritize assessing and addressing the low blood pressure to prevent further complications and ensure the patient's stability. The nurse should promptly notify the healthcare provider and implement appropriate interventions, such as administering intravenous fluids, to increase blood pressure to a safe level.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A client recovering from heart surgery develops pericarditis and reports level 6 (0 to 10 scale) chest pain with deep breathing. Which prescribed PRN medication will be the most appropriate for the nurse to give?

Correct Answer is C

Explanation

client with acute coronary syndrome has returned to the coronary care unit after having angioplasty with stent placement. Which assessment data indicate the need for immediate action by the nurse?

Correct Answer is C

Explanation

Which diagnostic test will be most useful to the nurse in determining whether a client admitted with acute shortness of breath has heart failure?

Which statement by a client with newly diagnosed heart failure indicates to the nurse that teaching was effective?

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?

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

Which information is most important for the nurse to include when teaching a client newly diagnosed with hypertension?

A nurse is providing dietary teaching to a client who has chronic kidney disease (CKD). The nurse should instruct the client to limit which of the following nutrients? (Select all that apply.)

Which topic will the nurse plan to include in discharge teaching for a client who has heart failure with reduced ejection fraction?

During the 48 hours after a myocardial infarction (MI), a nurse should assign the highest priority to monitoring the patient for what complication?