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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse should teach the client that the transthoracic echocardiography is a noninvasive test and that nothing will be inserted into the client's body.
Transthoracic echocardiography is a diagnostic procedure that uses ultrasound to create images of the heart's structures and assess its function. It is a noninvasive test, meaning that it does not involve any insertion of instruments or devices into the body. Instead, a transducer is placed on the chest to obtain images of the heart.
The statement about managing pain aggressively during the procedure is not applicable to transthoracic echocardiography. It is generally a painless procedure that does not cause discomfort.
Transthoracic echocardiography primarily provides detailed images of the heart's structures and function, such as the chambers, valves, and pumping action. It does not specifically profile the heart's electrical activity, which is usually assessed using an electrocardiogram (ECG) or other specialized tests.
Regarding bed rest after the test, there is typically no need for bed rest following transthoracic echocardiography. The client can usually resume normal activities immediately after the procedure. However, the nurse should provide specific instructions based on the client's condition and any additional tests or interventions planned.
Correct Answer is D
Explanation
Choice D: This question is crucial as it addresses the client's adherence to their prescribed medication regimen for managing high blood pressure. Consistent medication use is essential for controlling blood pressure and reducing the risk of complications associated with hypertension. The elevated blood pressure reading suggests that the current medication regimen may not be effectively controlling the client's blood pressure. By assessing medication adherence, the nurse can determine if non-adherence is contributing to the high blood pressure reading or if adjustments to the medication regimen are required.
"Have you recently taken any antihistamines?": Asking about recent antihistamine use is not directly relevant to the client's high blood pressure reading of 210/106 mm Hg. Antihistamines are medications primarily used to relieve allergy symptoms and do not typically have a significant impact on blood pressure levels.
"Have there been recent stressful events in your life?": While stress can contribute to temporary increases in blood pressure, asking about recent stressful events is not the most critical follow-up question in this situation. The client's blood pressure reading of 210/106 mm Hg indicates a severe elevation that requires immediate attention and management beyond stress reduction alone.
"Did you take any acetaminophen today?": Acetaminophen, also known as paracetamol, is a pain reliever and fever reducer. It does not typically have a significant effect on blood pressure. Therefore, asking about acetaminophen use is not the most relevant follow-up question for the client's high blood pressure reading.
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