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

The patient is apneic (not breathing) and has no palpable pulses, indicating a cardiac arrest or severe cardiovascular compromise. In this situation, the most appropriate action for the nurse to take next is to start cardiopulmonary resuscitation (CPR) immediately.

CPR is a life-saving procedure that combines chest compressions and rescue breaths to circulate oxygenated blood to vital organs when the heart is not effectively pumping. In the case of cardiac arrest, early initiation of CPR is critical to improve the chances of survival and minimize potential brain damage.

The heart monitor shows sinus tachycardia, rate 132, which suggests that the electrical impulses are reaching the heart, but the heart is not effectively pumping blood due to the lack of a palpable pulse. This condition requires immediate intervention with CPR rather than other treatments such as synchronized cardioversion (option A) or administering atropine (option D).

While applying supplemental oxygen via a non-rebreather mask (option C) is generally important in many emergency situations, it is not the immediate priority when a patient is apneic and has no palpable pulses. In such cases, CPR takes precedence to restore circulation and maintain oxygen delivery to the body's vital organs.

A. Most people are able to control BP through dietary changes. B. Annual BP checks are needed to monitor treatment effectiveness. C. Increasing physical activity controls blood pressure (BP) for most people. D. Hypertension is usually asymptomatic until target organ damage occurs.

Correct Answer is C

Explanation

Among the given options, the most important information for the nurse to include when teaching a client newly diagnosed with hypertension is option C, "Increasing physical activity controls blood pressure (BP) for most people."

Option C emphasizes the importance of increasing physical activity as a primary lifestyle modification to control blood pressure for most people with hypertension. Regular physical activity can help improve cardiovascular health, reduce blood pressure, and manage overall health. It is a proactive step that the individual can take immediately to start managing their hypertension.

Incorrect:

Option A, "Most people are able to control BP through dietary changes," is not necessarily true for everyone. While dietary changes, such as reducing sodium intake and adopting a heart-healthy diet, can be beneficial in managing hypertension, they may not be sufficient for everyone. Physical activity is an essential component of hypertension management and has broader health benefits.

Option B, "Annual BP checks are needed to monitor treatment effectiveness," is important information, but it is more of a recommendation for ongoing hypertension management rather than the most critical information for someone newly diagnosed with hypertension. Regular blood pressure monitoring is indeed crucial for treatment assessment and ensuring that the chosen treatment plan is effective.

Option D, "Hypertension is usually asymptomatic until target organ damage occurs," is important information to understand the nature of hypertension, but it does not provide immediate guidance for the newly diagnosed individual on how to manage their condition effectively.

As part of a comprehensive hypertension education plan, the nurse can provide additional information about dietary changes, regular blood pressure monitoring, and the importance of early management to prevent target organ damage. However, emphasizing physical activity as a fundamental aspect of hypertension management is the most important initial step for a newly diagnosed client. The nurse can then tailor the education based on the individual's specific needs and health status.

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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?

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Naxlex Comprehensive Predictor Exams

A patient is apneic and has no palpable pulses. The heart monitor shows sinus tachycardia, rate 132. What action should the nurse take next?

Correct Answer is B

Explanation

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

Correct Answer is C

Explanation

The nurse identifies that a patient with chronic kidney disease is at risk for which electrolyte disturbance?

A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?

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

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

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?

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