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

Explanation

"Have you recently taken any antihistamines?": This question is not directly related to the client's high blood pressure. Antihistamines are medications used to treat allergic reactions and have minimal impact on blood pressure.

"Have there been recent stressful events in your life?": Stress can affect blood pressure levels, so this question is relevant. Stressful events can trigger temporary increases in blood pressure. However, it is important to note that consistently high blood pressure readings require medical attention beyond stress management alone.

"Did you take any acetaminophen today?": Acetaminophen (also known as paracetamol) is a pain reliever and fever reducer. It does not have a significant impact on blood pressure levels. Therefore, this question may not directly address the issue of high blood pressure.

"Have you consistently taken your medications?" : This question is the most appropriate follow-up question for a client with a history of high blood pressure. It addresses medication adherence, which is crucial for managing hypertension. The client's blood pressure reading of 210/106 mm Hg suggests that their current medication regimen may not be effectively controlling their blood pressure. Assessing medication consistency will help determine if the elevated blood pressure is due to non-adherence or if a change in medication is required.

A. Use alcohol swabs to clean the skin before applying the leads B. Clip the chest hair with the patient's permission before applying the leads C. Apply the leads to the arms and legs only D. Reschedule the ECG

Correct Answer is B

Explanation

The most appropriate nursing intervention to improve adhesion of the ECG leads on a male client with abundant chest hair is to clip the chest hair with the patient's permission before applying the leads. Chest hair can interfere with the adhesion of the ECG leads, resulting in poor signal quality and potentially affecting the accuracy of the ECG recording. By clipping the chest hair, the nurse can improve the contact between the skin and the ECG leads, allowing for better adhesion and signal transmission.

It is important to obtain the patient's permission before clipping the chest hair to respect their autonomy and ensure their comfort during the procedure. The nurse should explain the reason for clipping the hair and address any concerns or questions the patient may have.

Let's review the other options and explain why they are not the most appropriate interventions:

Using alcohol swabs to clean the skin before applying the leads: While cleaning the skin with alcohol swabs is a routine practice to remove oils and dirt that can affect adhesion, it may not be sufficient in the presence of abundant chest hair. Clipping the hair would be more effective in this situation.

Applying the leads to the arms and legs only: This option would not provide an accurate 12-lead ECG recording, as the chest leads are essential for evaluating the electrical activity of the heart from different angles. It is important to have the leads properly placed on the chest for an accurate assessment.

Rescheduling the ECG: Unless there are other valid reasons for rescheduling, such as a medical condition that contraindicates the procedure, rescheduling solely due to abundant chest hair would be unnecessary. Clipping the hair is a practical and effective solution to improve adhesion.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client with a history of high blood pressure. The client's blood pressure is 210/106 mm Hg during the assessment. What follow-up question should the nurse ask?

Correct Answer is D

Explanation

The nurse is performing a 12-lead ECG on a male client with abundant chest hair. What is the most appropriate nursing intervention to improve adhesion of the ECG leads?

Correct Answer is B

Explanation

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