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 ["D","E"]

Explanation

The traces that should require immediate follow-up by the nurse are:

● Pacer spikes occur directly before the T waves.

Pacer spikes occurring on the T waves indicate an issue with the pacemaker's timing or sensing. This could lead to inappropriate pacing or pacing during the refractory period, which can be detrimental to the client's heart function.

● The heart rate is outside of programmed parameters.

If the heart rate is outside of the programmed parameters set for the client's pacemaker, it may indicate a malfunction or failure of the device or a change in the client's cardiac status. It is important for the nurse to assess the client's condition and notify the healthcare provider for further evaluation and intervention.

Let's review the other options and explain why they do not require immediate follow-up:

Pacer spikes are adequate in number: This indicates that the pacemaker is delivering the appropriate number of electrical impulses as programmed. As long as the other parameters are normal, this finding does not require immediate follow-up.

Pacer spikes occur directly before the P waves: This is the desired and expected pattern for a pacemaker in normal sinus rhythm. It indicates proper timing and coordination between the pacemaker and the client's intrinsic electrical activity.

Pacer spikes occur directly before the QRS waves: This is also the desired and expected pattern for a pacemaker in clients with ventricular pacing. It indicates proper timing and coordination between the pacemaker and the client's intrinsic electrical activity.

The heart rate is within programmed parameters: If the heart rate falls within the programmed parameters set for the client's pacemaker, it indicates that the device is functioning appropriately in maintaining the desired heart rate.

A. Assess the client's use of over-the-counter dietary supplements. B. Implement interventions relevant to arterial narrowing C. Encourage the client to increase intake of foods high in vitamin K D. Adjust the client's activity level to accommodate decreased coronary output.

Correct Answer is B

Explanation

The nurse should best follow up the assessment ﬁnding of an ankle-brachial index (ABI) of 0.40 in the right leg by implementing interventions relevant to arterial narrowing.

An ankle-brachial index is a non-invasive test used to assess peripheral arterial disease (PAD). An ABI value below 0.90 indicates signiﬁcant arterial narrowing and impaired blood ﬂow to the lower extremities. An ABI of 0.40 suggests severe arterial narrowing, which puts the client at risk for reduced perfusion and potential complications such as tissue ischemia, ulceration, and gangrene.

Implementing interventions relevant to arterial narrowing is crucial in this case. These interventions may include:

Collaborating with the healthcare provider to develop a treatment plan: This may involve prescribing medications to improve blood ﬂow, such as antiplatelet agents or vasodilators.
Encouraging lifestyle modiﬁcations: This can include smoking cessation, regular exercise, and maintaining a healthy diet low in saturated fats and high in fruits and vegetables.
Promoting optimal cardiovascular health: This can involve managing other risk factors for arterial narrowing, such as hypertension, diabetes, and high cholesterol levels.
Educating the client about the signs and symptoms of PAD: This includes teaching them to monitor for changes in skin color, temperature, and sensation in the affected limb, as well as the importance of seeking prompt medical attention if these changes occur.

Let's review the other options:

Assessing the client's use of over-the-counter dietary supplements: While it is important to assess for potential interactions between medications and dietary supplements, this would not be the immediate follow-up action for a severely reduced ABI.

Encouraging the client to increase intake of foods high in vitamin K: While maintaining a balanced diet is important for overall health, increasing vitamin K intake is not speciﬁcally indicated for addressing arterial narrowing or improving the ABI.

Adjusting the client's activity level to accommodate decreased coronary output:

Coronary output refers to blood ﬂow to the heart muscle. Arterial narrowing in the leg does not directly affect coronary output. However, it is important to encourage appropriate physical activity for the client based on their overall cardiovascular health and exercise tolerance.

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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 caring for a client with a pacemaker/ICD on a continuous cardiac monitor. Which trace should require immediate follow up by the nurse? Select all that apply

Correct Answer is ["D","E"]

Explanation

While assessing a client, the nurse notes that the client's ankle-brachial index (ABI) of the right leg is 0.40. How should the nurse best follow up this assessment ﬁnding?

Correct Answer is B

Explanation

The nurse is preparing to administer IV furosemide (Lasix) to a client with hypertension. What is the most important finding to report to the health care provider?

The nurse is assessing a client with a heart rate of 124 bpm. What clinical ﬁnding(s) should the nurse assess as causes of tachycardia? Select all that apply.

The nurse and unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP?

The nurse is providing discharge teaching to a client with venous insufficiency about compression stockings. Which information is essential for the nurse in the teaching plan?

The client is diagnosed with an abdominal aortic aneurysm. Which statement would the nurse expect the client to make during the admission assessment?

The nurse is teaching the community about blood pressure. What blood pressure finding by the nurse indicates that no changes in therapy are needed for a client with newly diagnosed hypertension?

The nurse is providing discharge education to a client who recently have insertion of a pacemaker/ICD. Which statement by the client should require further follow up by the nurse?

The nurse is reviewing the medical electronic record of a client with abdominal aortic aneurysm less than 3 cm in size. Which medical treatment should the nurse anticipate to be prescribed for the client?