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

The client reports a headache with pain at level 5 of 10.: While a headache can be a symptom of high blood pressure, a pain level of 5 out of 10 alone does not indicate an immediate life-threatening condition. It is important to assess and manage the client's pain, but it may not be the most critical ﬁnding to report in this situation.

The client has epistaxis after blowing his nose several times. : Epistaxis, or a nosebleed, can occur due to high blood pressure, but it is not the most urgent or critical symptom in a hypertensive emergency. While it is essential to address the nosebleed and monitor blood pressure, other symptoms may indicate more severe consequences of uncontrolled high blood pressure.

The client has a urine output of 120 mL over 4 hours.: While decreased urine output can be a concerning sign, it is not the most signiﬁcant ﬁnding to report in a hypertensive emergency. In this scenario, the focus is on acute complications related to high blood pressure, such as organ damage or impending stroke, which require immediate attention.

In summary, the ﬁnding that is most important to report to the healthcare provider in a client with a hypertensive emergency is the presence of new-onset blurry vision and facial asymmetry. These symptoms suggest potential neurological involvement and the need for urgent medical intervention to prevent serious complications like stroke.

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Correct Answer is A

Explanation

Hypertension is typically diagnosed when a person's blood pressure consistently exceeds 130/80 mm Hg on multiple occasions. However, the specific target blood pressure for treatment may vary based on individual factors and the presence of other comorbidities.

Among the options provided, a blood pressure reading of 128/76 mm Hg is within the target range for many individuals with hypertension. The systolic pressure (128 mm Hg) is below the threshold of 130 mm Hg, and the diastolic pressure (76 mm Hg) is below the threshold of 80 mm Hg.

The other blood pressure readings would warrant further evaluation or possible changes in therapy:

128/92 mm Hg: The diastolic pressure (92 mm Hg) is above the threshold of 80 mm Hg, indicating uncontrolled hypertension.

98/56 mm Hg: This blood pressure reading is below the threshold for hypertension, but it is considered low and may require further assessment to determine if it is normal for the individual or if it indicates hypotension.

142/78 mm Hg: While the systolic pressure (142 mm Hg) is slightly above the threshold of 130 mm Hg, it may not necessarily require immediate changes in therapy. However, it should be closely monitored to ensure blood pressure control.

A. The client has a permanent cardiac pacemaker B. The client has a history of atherosclerosis. C. The client took the prescribed heart medications today D. The client has an allergy to shellfish.

Correct Answer is A

Explanation

Having a permanent cardiac pacemaker is a significant factor that needs to be communicated to the health care provider before undergoing an MRI. Magnetic resonance imaging (MRI) uses powerful magnets, radio waves, and a computer to create detailed images of the body. The presence of a cardiac pacemaker can be a contraindication for undergoing an MRI because the strong magnetic field can potentially interfere with the functioning of the pacemaker or cause it to malfunction. It is crucial to assess the compatibility of the pacemaker with the MRI machine and to take appropriate precautions or make necessary arrangements to ensure the safety of the client during the procedure.

While the other pieces of information provided may be relevant to the client's overall health and medical history, they may not have a direct impact on the safety or feasibility of undergoing an MRI.

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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

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