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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

The importance of ensuring the stockings are applied evenly with no pressure points: Compression stockings are designed to provide graduated pressure to the legs, helping improve blood flow and reduce swelling in individuals with venous insufficiency. It is crucial for the client to understand how to properly apply the stockings to maximize their effectiveness and prevent any complications. The nurse should emphasize the following points:

● Ensure the stockings are applied evenly: The stockings should be applied smoothly and evenly without any folds or wrinkles. This helps ensure that the pressure is distributed uniformly, enhancing their therapeutic effect.

● Check for pressure points: The client should be instructed to pay attention to any areas where the stockings may be causing excessive pressure or discomfort. Pressure points can impair circulation or cause skin damage. If pressure points are noticed, adjustments should be made to ensure proper fit and comfort.

● Follow manufacturer's instructions: The nurse should provide specific instructions regarding how to correctly don the compression stockings, including any specific guidelines provided by the manufacturer. This may include recommendations for the time of day to apply the stockings or any specific donning techniques.

The other options mentioned in the question are not essential information for the teaching plan:

The need to take anticoagulants concurrent with using compression stockings: While some individuals with venous insufficiency may require anticoagulant therapy, it is not directly related to the use of compression stockings. Anticoagulant therapy is typically prescribed for other reasons, such as prevention or treatment of blood clots.

The need to wear the stockings on a one day on, one day off schedule: Wearing compression stockings on a specific schedule of one day on, one day off is not a standard recommendation. The frequency and duration of wearing compression stockings may vary based on individual needs and healthcare provider's recommendations.

The importance of wearing the stockings around the clock to ensure maximum benefit: While consistent and regular use of compression stockings is important, it is not necessary to wear them around the clock. Healthcare providers typically provide specific guidelines on how long the stockings should be worn each day, which may vary based on the severity of venous insufficiency and individual factors.

A. “I have stomach pain every time I eat a big, heavy meal." B. “I don't have any abdominal pain or any type of problems." C. “I have periodic episodes of constipation and then diarrhea." D. “I belch a lot especially when I lay down after eating"

Correct Answer is B

Explanation

Abdominal aortic aneurysms (AAA) often do not present with speciﬁc symptoms in the early stages. It is not uncommon for individuals with AAA to be asymptomatic or have vague symptoms. Therefore, the absence of abdominal pain or any problems related to the abdomen is a common ﬁnding during the assessment of a client with an abdominal aortic aneurysm.

Let's brieﬂy review the other statements:

"I have stomach pain every time I eat a big, heavy meal": This statement is more suggestive of gastrointestinal issues such as indigestion or acid reﬂux rather than speciﬁcally related to an abdominal aortic aneurysm.

"I have periodic episodes of constipation and then diarrhea": This statement may indicate gastrointestinal issues, but it is not a typical symptom associated with an abdominal aortic aneurysm. AAA is primarily related to the aorta, the main blood vessel in the abdomen, and its symptoms are not directly linked to bowel function.

"I belch a lot, especially when I lay down after eating": This statement suggests gastrointestinal symptoms such as acid reﬂux or gastroesophageal reﬂux disease (GERD). While these symptoms may be unrelated to the abdominal aortic aneurysm itself, they can coexist with other conditions.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

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?

Correct Answer is D

Explanation

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

Correct Answer is B

Explanation

A nurse is preparing a client for scheduled transesophageal echocardiography. Which action should the nurse perform?

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 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?

Which assessment data would require immediate intervention by the nurse for the client who is six (6) hours post-operative abdominal aortic aneurysm repair?

The nurse is teaching a client with peripheral arterial disease. Which information should the nurse include in the teaching plan?

The nurse is discussing discharge teaching with the client who is three (3) days post-operative abdominal aortic aneurysm repair. Which information should the nurse include in the teaching?

The nurse is conducting client teaching about cholesterol levels. When discussing the client's elevated LDL and lowered HDL levels, the client shows an understanding of the significance of these levels by making what statement?

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