The nurse is assessing a client with a hypertensive emergency. Which finding is most important to report to the health care provider?

The client reports a headache with pain at level 5 of 10

The client has epistaxis after blowing his nose several times

The client has a urine output of 120 mL over a 4 hours

The client has a new-onset blurry vision and facial asymmetry

Answer and Explanation

The Correct Answer is D

Among the given findings, the most important finding to report to the health care provider in a client with a hypertensive emergency is the new-onset blurry vision and facial asymmetry. These symptoms may indicate that the client is experiencing a hypertensive crisis with potential complications such as hypertensive encephalopathy or stroke.

Blurred vision and facial asymmetry are concerning neurological symptoms that suggest possible damage to the blood vessels or organs in the brain. It is crucial to notify the health care provider immediately so that appropriate interventions can be initiated to address the underlying cause and prevent further complications.

While the other findings may also be associated with elevated blood pressure, the new-onset blurry vision and facial asymmetry indicate possible neurological involvement and require immediate attention. Headache, epistaxis (nosebleed), and decreased urine output may be significant symptoms, but the potential neurological implications make the new-onset blurry vision and facial asymmetry the priority for reporting.

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Correct Answer is B

Explanation

Defibrillation is not the first-line treatment for atrial fibrillation. It is used to treat life-threatening cardiac arrhythmias such as ventricular fibrillation or pulseless ventricular tachycardia. Atrial fibrillation, on the other hand, is a rapid and irregular atrial rhythm, and defibrillation is not indicated for its treatment.

Obtain consent for transesophageal echocardiogram (TEE): This is an appropriate action for a client with atrial fibrillation. A TEE is often performed to assess the structure and function of the heart in cases of atrial fibrillation, especially when considering cardioversion or other interventions.

Obtain consent for cardioversion: Cardioversion is a common treatment option for atrial fibrillation, especially when the client is unstable or experiencing symptoms. It involves restoring a normal heart rhythm through the use of electrical shocks or medications. It is important to obtain informed consent before performing cardioversion, but this does not necessarily require questioning.

Hold digoxin 48 hours prior to cardioversion: Digoxin is commonly held before cardioversion because it can increase the risk of certain arrhythmias during the procedure. This is a standard precaution to minimize potential adverse effects. Therefore, the nurse does not need to question this action, as it aligns with established guidelines.

A. Organize nursing activities so that the patient has 8 hours of undisturbed sleep at night. B. Use an automated noninvasive blood pressure machine to obtain frequent measurements. C. Keep the hypertensive emergency NPO to prevent aspiration caused by nausea and possible vomiting. D. Assist the patient up in the chair for meals to avoid complications associated with immobility.

Correct Answer is B

Explanation

The action that will be included in the plan of care for a client in a hypertensive emergency receiving nifedipine is to use an automated noninvasive blood pressure machine to obtain frequent measurements.

In a hypertensive emergency, the client's blood pressure is severely elevated, requiring immediate treatment and close monitoring. Nifedipine is a calcium channel blocker commonly used to lower blood pressure in such situations. Continuous blood pressure monitoring is crucial to assess the effectiveness of the medication and ensure that the blood pressure is brought under control safely.

Organize nursing activities so that the patient has 8 hours of undisturbed sleep at night: While providing a conducive environment for sleep is important for overall patient well-being, in a hypertensive emergency, the priority is to manage and monitor the blood pressure. Sleep hygiene may not be the immediate concern in this situation.

Keep the hypertensive emergency NPO to prevent aspiration caused by nausea and possible vomiting: NPO (nothing by mouth) orders are typically implemented when there is a risk of aspiration or pending a procedure requiring anesthesia. In a hypertensive emergency, the focus is on managing blood pressure and ensuring appropriate hydration and nutrition as needed. NPO status may not be necessary unless speciﬁcally indicated for the individual patient.

Assist the patient up in the chair for meals to avoid complications associated with immobility: While mobilization and preventing complications associated with immobility are important aspects of care, in a hypertensive emergency, the primary focus is on managing blood pressure and stabilizing the client's condition. Mobilization may be appropriate once the blood pressure is under control and the client's condition permits.

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The nurse is assessing a client with a hypertensive emergency. Which finding is most important to report to the health care provider?

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Naxlex Comprehensive Predictor Exams

The nurse is reviewing the medical records of a client with atrial fibrillation. Which prescription should the nurse question?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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