Hypertension Hesi
What is the best response by the nurse?
-"This is a frightening experience. Is there someone with whom you would like to talk about your fears?" (The nurse acknowledges George's feelings and addresses the issue.)
Which result indicates that this task was successfully delegated?
-The UAP reports the current vital signs to the nurse. (For delegation to be complete, not only must the right task be assigned to the right person and completed, but the results must be reviewed by the nurse.)
How should the nurse respond to George's question?
-"90 to 95% of all cases of hypertension are without an identified cause, so unless there is some indicator in your health history, the HCP does not look for one." (Primary (essential) hypertension has no identifiable cause, even though there are several known contributing factors.)
Which statement by his wife shows she understands a 2 gm sodium diet?
-"I am preparing a variety of fresh vegetables and avoiding processed foods." (Processed foods are a major source of sodium. Replacing processed foods with fresh is a key to maintaining a low-sodium diet.)
While evaluating George's understanding, which statements indicate that George understands the nurse's instructions about his medications?
-"I will need to take Diuril early in the day." (Since Diuril is a diuretic, taking it later in the day may disrupt the client's sleep.) -"I may experience impotence with this drug regimen." (This is a common side effect of many antihypertensive medications, including atenolol (Tenormin), which is a beta blocker.) -"I should avoid drinking alcohol." (Alcohol may increase the chance of dizziness occurring.)
What statement by George indicates to the nurse that he understands his current plan of care?
-"If my blood pressure is in the normal range on my next visit, I will probably continue on these medications for at least 1 year." (Step-down therapy is not started until after 1 year of good blood pressure control.)
George is complaining of extreme pain. The HCP prescribes morphine sulfate 8 mg IV push. The available form is a 5 mL container of morphine sulfate labeled 2 mg/mL. How many milliliters should the nurse draw up for one dose? (Enter numeric value only. If rounding is necessary, round to the whole number.) 2 mg/mL x 4 mL = 8 mg
-4
What is the nurse's best initial response?
-Acknowledge the son's anger. (Understanding that the son's anger is not directed personally at the nurse will help the nurse respond to the son in an effective, caring manner.)
How should the nurse respond to George's concern?
-Advise him that his HCP may want to do further testing because of his family history. (Studies have shown a strong genetic predisposition in the development of abdominal aortic aneurysms. This response provides immediate feedback that addresses the client's concern.)
What significant risk factors for hypertension does the student nurse identify for George, according to this health history?
-Alcohol consumption (Excessive alcohol intake is strongly associated with hypertension.) -Smoking (Tobacco use is a risk factor for hypertension.) -Stress (High levels of stress can lead to an increase in blood pressure.)
What instruction related to this medication is essential for the nurse to provide George?
-Avoid eating fresh grapefruit or grapefruit juice. (Grapefruit decreases the effectiveness of nifedipine (Procardia), a calcium channel blocker.)
What other interventions should the nurse perform prior to sending George to the operating room (OR)?
-Begin continuous cardiac monitoring. (George will need to be assessed for tachycardia and other irregular rhythms.) -Insert a second large bore angiocath if one does not exist. (Patent and reliable IV access for fluid or blood administration is essential.)
Which information obtained during the assessment supports this diagnosis?
-Blood pressure of 184/98 mmHg. (Stage 2 hypertension is described as a systolic blood pressure of greater than or equal to 160 mmHg or a diastolic blood pressure of greater than or equal to 100 mmHg.)
In addition to talking with George's children and preparing his body for transport to the morgue, what action must the surgical nurse perform?
-Call the organ procurement agency for the region. (Federal law requires the nurse to notify the organ procurement agency for their region with all hospital deaths.)
Which assessment finding is of most concern to the nurse?
-Current blood pressure reading of 148/90 mmHg. (George's blood pressure is still hypertensive. With the presence of an abdominal aortic aneurysm (AAA), attaining and maintaining a normal blood pressure is essential.)
What resource is most valuable for the nurse to use to resolve this situation?
-The hospital ethics committee. (The nurse needs to have others involved in this decision. Consulting the ethics committee is the appropriate channel to take to resolve this ethical dilemma.)
Which action can be safely delegated to the unlicensed assistive personnel (UAP)?
-Document a list of George's personal belongings. (This is the only action listed that does not require the expertise of the nurse.)
What is the most effective nursing intervention to help George be successful this time?
-Encourage George to make a quit plan. (A quit plan, which includes the quit date, notifying friends and relatives of the plan to quit, anticipating withdrawal symptoms, and throwing away all tobacco products on the quit date is an excellent method to quit smoking. Using more than one method helps ensure success. George's use of the nicotine gum along with a quit plan may increase the potential for success.)
Considering the overall plan of care, what is the primary reason for the nurse to encourage George to keep his next appointment?
-Follow-up measurement of his blood pressure. (George has just been started on antihypertensive medications. The effectiveness of this treatment needs to be assessed. Many people who are on antihypertensive medications are still hypertensive. Follow-up evaluation is essential.)
Which assessment data obtained during the triage assessment alerts the nurse that George needs immediate medical evaluation?
-History of 3 cm aortic aneurysm and sudden onset of back pain. (The sudden onset of back pain in the client with a history of an aneurysm is a sign that the aneurysm may be dissecting or may have ruptured.)
Which order should the nurse complete first?
-IV of 0.9% Normal Saline (NS) with large bore angiocath. (When a dissecting or ruptured aneurysm occurs, the client requires large amounts of fluid replacement to maintain the blood pressure. It is essential that an IV be started before George's blood pressure starts to fall.)
Based on the data the nurse has obtained, which nursing diagnosis should be included in the plan of care?
-Ineffective health maintenance. (George remains hypertensive. His treatment regimen needs to be reevaluated in order for George to become normotensive.)
In teaching George about the aneurysm, what information should the nurse include?
-Maintaining a normal blood pressure can effectively treat this size of aneurysm. (For aneurysms smaller than 5 cm in size, the treatment of choice is to keep the client's blood pressure under control and to monitor the size of the aneurysm every 6 months.)
How should the nurse respond?
-Many methods can help reduce stress. Tell me about your work day. (With this response, the nurse helps George identify strategies that might fit into his lifestyle. This response empowers the client to be engaged in the process of determining which strategy will be most effective for him.)
George's blood pressure reading is 189/110 mmHg. His LDL cholesterol reading is 200 mg/dL. He asks the student nurse if he should be concerned about his blood pressure. How should the student nurse respond?
-Please sit here quietly for a few minutes. I need to recheck your blood pressure. (George's blood pressure is high but may be temporarily elevated due to activity or stress. The blood pressure should be rechecked after the client rests for a few minutes.)
According to the assessment of this client, which recommendation is most important for the student nurse to provide to George?
-See his HCP as soon as possible within the next week for a BP recheck. (George's blood pressure is significantly elevated. Since these BP readings were obtained on the same day, George needs to see his HCP soon for a second BP measurement so that a diagnosis can be determined and treatment initiated.)
How should the nurse respond?
-Talk further with the children and explore options with them. (The nurse needs to do a further assessment and allow the children to communicate their concerns.)
When discussing these lifestyle modifications with George, what information is most important for the nurse to share?
-Use of tobacco products is linked with increased risk for cardiovascular disease. (Discontinuation of tobacco use decreases blood pressure and has cardiovascular benefits within the first year of quitting.)
Which is the best response the student nurse can give to the George about the urgent need to see his HCP?
-While often there are no symptoms, high blood pressure does cause damage to many organs. (Often clients with hypertension have no symptoms, and organ damage may occur before the client becomes symptomatic.)
Place the nursing actions in numerical order from the first action through the last action.
1. Notify George's children and family. 2. Call report to the operating room staff. 3. Get the surgical consent form signed. 4. Consult a social worker. (It is imperative to follow hospital protocol during this time. A significant number of clients who have surgery to repair a dissecting abdominal aortic aneurysm do not live through the surgery. Mark and his family need time to connect before the surgery, so this is the priority nursing action. Calling the OR should be done immediately after notifying the family, to allow adequate time for OR preparation. The surgeon will then need to inform the client about the procedure and the risks involved, as well as obtain the client's signed consent form. Consulting a social worker to help the family deal with psychosocial issues is important, but it is the last priority.)
