The nurse on the intermediate care unit received change-of-shift report on four clients with hypertension. Which patient should the nurse assess first?
A client with a blood pressure of 190/92 mm Hg who reports chest pain
A client with a blood pressure of 190/104 mm Hg who has sinus tachycardia
A client with a blood pressure of 178/90 mm Hg who has intermittent claudication
A client with a blood pressure of 172/98 mm Hg scheduled for a stress test
The Correct Answer is A
The nurse should assess the client with a blood pressure of 190/92 mm Hg who reports chest pain first. Chest pain can be a symptom of myocardial ischemia or a heart attack, which requires immediate attention. The combination of high blood pressure and chest pain is concerning and may indicate acute coronary syndrome. Prompt assessment and intervention are crucial to evaluate the cause of the chest pain and initiate appropriate treatment.
A client with a blood pressure of 190/104 mm Hg who has sinus tachycardia: While sinus tachycardia may indicate increased heart rate, it does not necessarily require immediate assessment unless other concerning symptoms are present. However, the nurse should address the elevated blood pressure in a timely manner.
Intermittent claudication refers to leg pain or discomfort during physical activity due to reduced blood flow. While it is important to assess and manage this symptom, it is not typically considered an urgent condition requiring immediate assessment compared to chest pain.
The client scheduled for a stress test may have elevated blood pressure, but if they are stable and not currently experiencing symptoms, they may not require immediate assessment compared to a client with chest pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
Sinus bradycardia with a heart rate of 32 beats/min and accompanying hypotension and symptoms of feeling faint indicates significant hemodynamic compromise. In such cases, the first-line intervention is to provide external cardiac pacing through transcutaneous pacemaker (TCP) pads. TCP can help increase the heart rate and improve cardiac output by delivering electrical impulses to the heart.
Administering the scheduled dose of diltiazem (Cardizem), a calcium channel blocker, is not appropriate in this situation. Diltiazem can further lower the heart rate and blood pressure, exacerbating the client's symptoms and potentially leading to adverse effects.
Repositioning the patient on the left side or having the patient perform the Valsalva maneuver are not effective interventions for treating sinus bradycardia with hemodynamic compromise. These actions may be used in specific situations, but in this case, the client requires immediate intervention to address the low heart rate and blood pressure.
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