Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown origin?

Explain the association between dysrhythmias and syncope.

Tell the patient about the benefits of implantable cardioverter-defibrillators.

Instruct the patient to call for assistance before getting out of bed.

Teach the patient about the need to avoid caffeine and other stimulants.

Answer and Explanation

The Correct Answer is C

For a patient admitted with syncopal (fainting) episodes of unknown origin, the most appropriate action to include in the plan of care is to instruct the patient to call for assistance before getting out of bed.

Syncope can be caused by various factors, including orthostatic hypotension (a drop in blood pressure upon standing) or cardiac-related issues. One of the common triggers for syncopal episodes is getting up from a lying or sitting position too quickly. By instructing the patient to call for assistance before getting out of bed, the nurse aims to prevent falls and potential injuries that may occur due to sudden fainting episodes.

While it's essential to educate the patient about potential causes of syncope (option A) and the benefits of implantable cardioverter-defibrillators (option B) if applicable to their condition, these actions may not directly address the immediate safety concern of preventing falls during syncopal episodes.

Option D, teaching the patient about the need to avoid caffeine and other stimulants, may be relevant if stimulants are identified as potential triggers for syncope in this particular patient. However, it is not the most critical action to include in the initial plan of care for a patient with syncopal episodes of unknown origin.

In summary, the top priority for the nurse is to ensure the safety of the patient by instructing them to call for assistance before getting out of bed to prevent falls during syncopal episodes until further evaluation and diagnosis can determine the cause of the fainting episodes.

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Correct Answer is B

Explanation

The client presenting to the emergency department with a severe headache, nausea, and significantly elevated blood pressure (BP) of 238/118 mm Hg indicates a hypertensive crisis, which is a severe and potentially life-threatening condition. In such cases, the nurse's priority is to assess for potential triggers or exacerbating factors for the hypertensive crisis.

Option B, "Have there been recent stressful events in your life?" is the most relevant question to follow up on the findings. Stress is a known trigger for acute elevations in blood pressure, and severe stress can lead to a hypertensive crisis in individuals with a history of hypertension. Identifying recent stressful events may help the nurse understand potential contributing factors to the client's current condition and guide the management plan.

Option A, "Have you recently taken any antihistamines?" is not the most relevant question in this situation. Antihistamines are not typically associated with causing a hypertensive crisis. While certain medications and substances can interact with antihypertensive medications, causing an increase in BP, the severity of the client's symptoms and the extremely high BP reading suggest that a more immediate concern needs to be addressed.

Option C, "Have you consistently taken your medications?" is important for assessing medication adherence, but it may not directly explain the acute hypertensive crisis. The client's current symptoms and BP reading require more immediate investigation into potential triggers.

Option D, "Did you take any aspirin (or Tylenol) today?" is relevant to assess whether the client has recently taken any over-the-counter medications that could potentially interact with their prescribed antihypertensive drugs. However, it is not the most critical question to address the hypertensive crisis and the severity of the client's symptoms.

Given the severity of the client's presentation, the nurse should also promptly initiate appropriate interventions to address the hypertensive crisis, such as administering antihypertensive medications as prescribed, monitoring vital signs frequently, and notifying the healthcare provider for further evaluation and management.

A. 52-yr-old with a blood pressure of 198/90 mm Hg who has intermittent claudication. B. 48-yr-old with a blood pressure of 160/92 mm Hg who reports chest pain. C. 43-yr-old with a blood pressure of 172/98 mm Hg whose urine shows microalbuminuria. D. 50-yr-old with a blood pressure of 190/104 mm Hg who has a creatinine of 1.7 mg/dL.

Correct Answer is B

Explanation

Among the four patients with hypertension, the nurse should assess the patient in option B first, the 48-year-old with a blood pressure of 160/92 mm Hg who reports chest pain.

Chest pain is a potentially serious symptom that could indicate an acute cardiac event, such as angina or a heart attack. Given that the patient has hypertension and is experiencing chest pain, the nurse must prioritize this assessment to rule out any cardiac-related complications or other urgent issues.

While all the other patients have elevated blood pressure readings, they have additional symptoms or conditions that indicate potential complications related to their hypertension. However, chest pain is a red flag that requires immediate attention and further assessment to determine its cause and provide appropriate interventions promptly.

Option A, the 52-year-old with a blood pressure of 198/90 mm Hg who has intermittent claudication, may have peripheral vascular disease or other vascular issues related to hypertension, but it is not as acutely concerning as chest pain.

Option C, the 43-year-old with a blood pressure of 172/98 mm Hg whose urine shows microalbuminuria, may have early signs of kidney involvement due to hypertension, which is significant and requires attention but may not be as immediately urgent as chest pain.

Option D, the 50-year-old with a blood pressure of 190/104 mm Hg who has a creatinine of 1.7 mg/dL, may have signs of kidney impairment related to hypertension, which is also significant but may not be as acutely urgent as chest pain.

In summary, the nurse should prioritize the assessment of the patient experiencing chest pain (option B) to address any potential cardiac-related issues promptly and ensure appropriate management and intervention.

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Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown origin?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse on the intermediate care unit received a change-of-shift report on four patients with hypertension. Which patient should the nurse assess first?

Correct Answer is B

Explanation

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