Chapter 32: Hypertension

The nurse teaches a 28-yr-old man newly diagnosed with hypertension about lifestyle modifications to reduce his blood pressure. Which patient statement requires reinforcement of teaching? "I will avoid adding salt to my food during or after cooking." "If I lose weight, I might not need to continue taking medications." "I can lower my blood pressure by switching to smokeless tobacco." "Diet changes can be as effective as taking blood pressure medications."

"I can lower my blood pressure by switching to smokeless tobacco." Rationale: Nicotine contained in tobacco products (smoking and chew) cause vasoconstriction and increase blood pressure. Persons with hypertension should restrict sodium to 1500 mg/day by avoiding foods high in sodium and not adding salt in preparation of food or at meals. Weight loss can decrease blood pressure between 5 to 20 mm Hg. Following dietary recommendations (e.g., the DASH diet) lowers blood pressure, and these decreases compare with those achieved with blood pressure-lowering medication.

When providing dietary teaching to a patient with hypertension, the nurse would teach the patient to restrict intake of which meat? Broiled fish Roasted duck Roasted turkey Baked chicken breast

Roasted Duck Roasted duck is high in fat, which should be avoided by the patient with hypertension. Weight loss may slow the progress of atherosclerosis and overall cardiovascular disease risk. The other meats are lower in fat and are therefore acceptable in the diet.

Despite a high dosage, a male patient who is taking nifedipine (Procardia XL) for antihypertensive therapy continues to have blood pressures over 140/90 mm Hg. What should the nurse do next? Assess his adherence to therapy. AnswerAsk him to make an exercise plan. Teach him to follow the DASH diet. Request a prescription for a thiazide diuretic.

Assess his adherence to therapy. Rationale: A long-acting calcium-channel blocker such as nifedipine causes vascular smooth muscle relaxation, resulting in decreased systemic vascular resistance and arterial blood pressure and related side effects. The patient data the nurse has about this patient is very limited, so the nurse needs to begin by assessing adherence to therapy.

The nurse is caring for a patient admitted with chronic obstructive pulmonary disease (COPD), angina, and hypertension. Before administering the prescribed daily dose of atenolol 100 mg PO, the nurse assesses the patient carefully. Which adverse effect is this patient at risk for given the patient's health history? Hypocapnia Tachycardia Bronchospasm Nausea and vomiting

Bronchospasm Rationale: Atenolol is a cardioselective β1-adrenergic blocker that reduces blood pressure and could affect the β2-receptors in the lungs with larger doses or with drug accumulation. Although the risk of bronchospasm is less with cardioselective β-blockers than nonselective β-blockers, atenolol should be used cautiously in patients with COPD.

The nurse supervises an unlicensed assistant personnel (UAP) who is taking the blood pressure of an obese patient admitted with heart failure. Which action by the UAP will require the nurse to intervene? Deflating the blood pressure cuff at a rate of 8 to 10 mm Hg/sec. Waiting 2 minutes after position changes to take orthostatic pressures. Taking the blood pressure with the patient's arm at the level of the heart. Taking a forearm blood pressure if the largest cuff will not fit the patient's upper arm.

Deflating the blood pressure cuff at a rate of 8 to 10 mm Hg/sec Rationale: The cuff should be deflated at a rate of 2 to 3 mm Hg/sec. The arm should be supported at the level of the heart for accurate blood pressure measurements. Using a cuff that is too small causes a falsely high reading and too large causes a falsely low reading. If the maximum size blood pressure cuff does not fit the upper arm, the forearm may be used. Orthostatic blood pressures should be taken within 1 to 2 minutes of repositioning the patient.

A patient with a history of chronic hypertension is being evaluated in the emergency department for a blood pressure of 200/140 mm Hg. Which patient assessment question is the priority? Is the patient pregnant? Does the patient need to urinate? Does the patient have a headache or confusion? Is the patient taking antiseizure medications as prescribed?

Does the patient have a headache or confusion? Rationale: The nurse's priority assessments include neurologic deficits, retinal damage, heart failure, pulmonary edema, and renal failure. The headache or confusion could be seen with hypertensive encephalopathy from increased cerebral capillary permeability leading to cerebral edema. In addition, headache or confusion could represent signs and symptoms of a hemorrhagic stroke. Pregnancy can lead to secondary hypertension. Needing to urinate and taking antiseizure medication do not support a hypertensive emergency.

The nurse teaches a patient with hypertension that uncontrolled hypertension may damage organs in the body primarily by which mechanism? Hypertension promotes atherosclerosis and damage to the walls of the arteries. Hypertension causes direct pressure on organs, resulting in necrosis and scar tissue. Hypertension causes thickening of the capillary membranes, leading to hypoxia of organ systems. Hypertension increases blood viscosity, which causes intravascular coagulation and tissue necrosis distal to occlusions.

Hypertension promotes atherosclerosis and damage to the walls of the arteries. Rationale: Hypertension is a major risk factor for the development of atherosclerosis by mechanisms not yet fully known. However, when atherosclerosis develops, it damages the walls of arteries and reduces circulation to target organs and tissues.

The nurse is teaching a women's group about ways to prevent hypertension. What information should the nurse include? (Select all that apply.) Lose weight Limit beef consumption. Limit sodium and fat intake. Increase fruits and vegetables. Exercise 30 minutes most days.

Limit beef consumption. increase fruits and vegetables Limit sodium and fat intake. Exercise 30 minutes most days. Rationale: Primary prevention of hypertension is to make lifestyle modifications that prevent or delay the increase in BP. Along with exercise for 30 minutes on most days, the DASH eating plan is a healthy way to lower BP by limiting sodium and fat intake, increasing fruits and vegetables, and increasing nutrients that are associated with lowering BP. Beef includes saturated fats, which should be limited. Weight loss may or may not be necessary, depending on the person.

The nurse is caring for a patient with hypertension who is scheduled to receive a dose of metoprolol (Lopressor). The nurse should withhold the dose and consult the prescribing provider for which vital sign taken just before administration? O2 saturation 93% Pulse 48 beats/min Respirations 24 breaths/min Blood pressure 118/74 mm Hg

Pulse 48 beats/min Rationale: Because metoprolol is a β1-adrenergic blocking agent, it can cause hypotension and bradycardia as adverse effects. The nurse should withhold the dose and consult with the health care provider for parameters regarding pulse rate limits.

When teaching a patient about dietary management of stage 1 hypertension, which instruction is appropriate? Increase water intake. Restrict sodium intake. Increase protein intake. Use calcium supplements.

Restrict sodium intake. Rationale: The patient should decrease intake of sodium. This will help to control hypertension, which can be aggravated by excessive salt intake, which in turn leads to fluid retention. Protein intake does not affect hypertension. Calcium supplements are not recommended to lower blood pressure.

Which information should the nurse consider when planning care for older adult patients with hypertension? (Select all that apply.) Systolic blood pressure increases with aging. White coat syndrome is prevalent in older patients. Volume depletion contributes to orthostatic hypotension. Blood pressures should be maintained near 120/80 mm Hg. Blood pressure drops 1 hour after eating in many older patients. Older patients require higher doses of antihypertensive medications.

Systolic blood pressure increases with aging. White coat syndrome is prevalent in older patients. Volume depletion contributes to orthostatic hypotension. Blood pressure drops 1 hour after eating in many older patients. Rationale: Systolic blood pressure increases with age and patients older than age 60 years should be maintained below 150/90 mm Hg. Older adults are more likely to have elevated blood pressure when taken by health care providers (white coat syndrome). Older patients have orthostatic hypotension related to dehydration, reduced compensatory mechanisms, and medications. One hour after eating, many older patients have a drop in blood pressure. Lower doses of medications may be needed to control blood pressures in older adults related to decreased absorption rates and excretion ability.

The UAP is taking orthostatic vital signs. In the supine position, the blood pressure (BP) is 130/80 mm Hg, and the heart rate (HR) is 80 beats/min. In the sitting position, the BP is 140/80, and the HR is 90 beats/min. Which action should the nurse instruct the UAP to take next? Repeat BP and HR in this position. Record the BP and HR measurements. Take BP and HR with patient standing. Return the patient to the supine position.

Take BP and HR with patient standing. Rationale: The vital signs taken do not reflect orthostatic changes, so the UAP will continue with the measurements while the patient is standing. There is no need to repeat or delay the readings. The patient does not need to return to the supine position. When assessing for orthostatic changes, the UAP will take the BP and pulse in the supine position, then place the patient in a sitting position for 1 to 2 minutes and repeat the readings, and then reposition to the standing position for 1 to 2 minutes and repeat the readings. Results consistent with orthostatic changes would have a decrease of 20 mm Hg or more in systolic BP, a decrease of 10 mm Hg or more in diastolic BP, and/or an increase in HR of greater than or equal to 20 beats/min with position changes.

A patient with newly discovered high BP has an average reading of 158/98 mm Hg after 3 months of exercise and diet modifications. Which management strategy will be a priority for this patient? a. Medication will be required because the BP is still not at goal. b. BP monitoring should continue for another 3 months to confirm a diagnosis of hypertension. c. Lifestyle changes are less important, since they were not effective, and medications will be started. d. More vigorous changes in the patient's lifestyle are needed for a longer time before starting medications.

a

The nurse is providing care for a patient who has decreased cardiac output related to heart failure. What should the nurse recognize about cardiac output? a. Calculated by multiplying the patient's stroke volume by the heart rate b. The average amount of blood ejected during one complete cardiac cycle c. Determined by measuring the electrical activity of the heart and the patient's heart rate d. The patient's average resting heart rate multiplied by the patient's mean arterial blood pressure

a

When caring for elderly patients with hypertension, which information should the nurse consider when planning care (select all that apply.)? a. Systolic blood pressure increases with aging. b. Blood pressures should be maintained near 120/80 mm Hg. c. White coat syndrome is prevalent in elderly patients. d. Volume depletion contributes to orthostatic hypotension. e. Blood pressure drops 1 hour postprandially in many older patients. f. Older patients will require higher doses of antihypertensive medications.

a, c, d, e

A patient is admitted to the hospital in hypertensive emergency (BP 244/142 mm Hg). Sodium nitroprusside is started to treat the elevated BP. Which management strategy(ies) would be most appropriate for this patient (select all that apply)? a. Measuring hourly urine output b. Decreasing the MAP by 50% within the first hour c. Continuous BP monitoring with an arterial line d. Maintaining bed rest and providing tranquilizers to lower the BP e. Assessing the patient for signs and symptoms of heart failure and changes in mental status

a, c, e done

Which BP-regulating mechanism(s) can result in the development of hypertension if defective (select all that apply)? a. Release of norepinephrine b. Secretion of prostaglandins c. Stimulation of the sympathetic nervous system d. Stimulation of the parasympathetic nervous system e. Activation of the renin-angiotensin-aldosterone system

a, c, e yes

What are nonmodifiable risk factors for primary hypertension (select all that apply)? a. Age b. Obesity c. Gender d. Genetic link e. Ethnicity

a,c,d,e Hypertension progresses with increasing age. It is more prevalent in men up to age 45 and above the age of 64 in women. African Americans have a higher incidence of hypertension than do white Americans. Children and siblings of patients with hypertension should be screened and taught about healthy lifestyles.

A 78-year-old patient is admitted with a BP of 180/98 mm Hg. Which age-related physical changes may contribute to this patient's hypertension (select all that apply)? a. Decreased renal function b. Increased adrenergic receptor sensitivity c. Increased baroreceptor reflexes d. Increased collagen and stiffness of the myocardium e. Increased peripheral vascular resistance f. Loss of elasticity in large arteries from arteriosclerosis

a,d,e,f The age-related changes that contribute to hypertension include decreased renal function, increased peripheral vascular resistance, increased collagen and stiffness of the myocardium, and decreased elasticity in large arteries from arteriosclerosis.

The nurse teaches a patient with hypertension that uncontrolled hypertension may damage organs in the body primarily by which mechanism? a. Hypertension promotes atherosclerosis and damage to the walls of the arteries. b. Hypertension causes direct pressure on organs, resulting in necrosis and replacement of cells with scar tissue. c. Hypertension causes thickening of the capillary membranes, leading to hypoxia of organ systems. d. Hypertension increases blood viscosity, which contributes to intravascular coagulation and tissue necrosis distal to occlusions.

a.

What is the patient with primary hypertension likely to report? a. No symptoms b. Dyspnea on exertion c. Cardiac palpitations d. Dizziness and vertigo

a. Hypertension is often asymptomatic, especially if it is mild or moderate, and has been called the "silent killer."

During treatment of a patient with a BP of 222/148 mm Hg and confusion, nausea, and vomiting, the nurse initially titrates the medications to achieve which goal? a. Decrease the mean arterial pressure (MAP) to 129 mm Hg b. Lower the BP to the patient's normal within the second to third hour c. Reduce the systolic BP (SBP) to 158 mm Hg and the diastolic BP (DBP) to 111 mm Hg within the first 2 hours d. Decrease the SBP to 160 mm Hg and the DBP to between 100 and 110 mm Hg as quickly as possible

a. Initially the treatment goal in hypertensive emergencies is to reduce the mean arterial pressure (MAP) by no more than 20% to 25% in the first hour, with further gradual reduction over the next 24 hours. In this case the MAP is 172, so decreasing it by 25% equals 129. MAP = [(2 x diastolic)+systolic] / 3

What is most organ damage in hypertension related to? a. Increased fluid pressure exerted against organ tissue b. Atherosclerotic changes in vessels that supply the organs c. Erosion and thinning of blood vessels from constant pressure d. Increased hydrostatic pressure causing leakage of plasma into organ interstitial spaces

b

When teaching a patient about dietary management of stage 1 hypertension, which instruction is most appropriate? a. Restrict all caffeine. b. Restrict sodium intake. c. Increase protein intake. d. Use calcium supplements.

b

While obtaining subjective assessment data from a patient with hypertension, the nurse recognizes that a modifiable risk factor for the development of hypertension is a. a low-calcium diet. b. excessive alcohol intake. c. a family history of hypertension. d. consumption of a high-protein diet.

b

Which classification of drugs used to treat hypertension prevents the action of angiotensin II and promotes increased salt and water excretion? a. Thiazide diuretics b. Angiotensin II receptor blockers (ARBs) c. Direct vasodilators d. Angiotensin-converting enzyme (ACE) inhibitors

b. Angiotensin II receptor blockers (ARBs) prevent the action of angiotensin II and produce vasodilation and increased salt and water excretion.

The unit is very busy and short staffed. What could be delegated to the unlicensed assistive personnel (UAP)? a. Administer antihypertensive medications to stable patients. b. Obtain orthostatic blood pressure (BP) readings for older patients. c. Check BP readings for the patient receiving IV enalapril (Vasotec). d. Teach about home BP monitoring and use of automatic BP monitoring equipment

b. Unlicensed assistive personnel (UAP) may check postural changes in BP as directed. The licensed practical nurse (LPN) may administer antihypertensive medications to stable patients. The RN must monitor the patient receiving IV enalapril (Vasotec), as he or she is in a hypertensive crisis. The RN must also do the teaching related to home BP monitoring.

The nurse teaches a 28-yr-old man newly diagnosed with hypertension about lifestyle modifications to reduce his blood pressure. Which patient statement requires reinforcement of teaching? a. "I will avoid adding salt to my food during or after cooking." b. "If I lose weight, I might not need to continue taking medications." c. "I can lower my blood pressure by switching to smokeless tobacco." d. "Diet changes can be as effective as taking blood pressure medications.

c

How is secondary hypertension differentiated from primary hypertension? a. Has a more gradual onset than primary hypertension b. Does not cause the target organ damage that occurs with primary hypertension c. Has a specific cause, such as renal disease, that often can be treated by medicine or surgery d. Is caused by age-related changes in BP regulatory mechanisms in people over 65 years of age

c Secondary hypertension has an underlying cause that can often be treated, in contrast to primary or essential hypertension,which has no single known cause.

The nurse is teaching a women's group about prevention of hypertension. What information should be included in the teaching for all the women (select all that apply)? a. Lose weight. b. Limit nuts and seeds. c. Limit sodium and fat intake. d. Increase fruits and vegetables. e. Exercise 30 minutes most days.

c, d, e

Which manifestation is an indication that a patient is having a hypertensive emergency? a. Symptoms of a stroke with an elevated BP b. A systolic BP >200 mm Hg and a diastolic BP >120 mm Hg c. A sudden rise in BP accompanied by neurologic impairment d. A severe elevation of BP that occurs over several days or weeks

c. Hypertensive emergency, a type of hypertensive crisis, is a situation that develops over hours or days in which a patient's BP is severely elevated with evidence of acute target organ disease (e.g., cerebrovascular, cardiovascular, renal, or retinal). The neurologic manifestations are often similar to the presentation of a stroke but do not show the focal or lateralizing symptoms of stroke.

The patient who is being admitted has had a history of uncontrolled hypertension. High SVR is most likely to cause damage to which organ? a. Brain b. Retina c. Heart d. Kidney

c. The increased systemic vascular resistance (SVR) of hypertension directly increases the workload of the heart and heart failure occurs when the heart can no longer pump effectively against the increased resistance.

A priority consideration in the management of the older adult with hypertension is to a. prevent primary hypertension from converting to secondary hypertension. b. recognize that the older adult is less likely to adhere to the drug therapy regimen than a younger adult. c. ensure that the patient receives larger initial doses of antihypertensive drugs because of impaired absorption. d. use careful technique in assessing the BP of the patient because of the possible presence of an auscultatory gap.

d

In teaching a patient with hypertension about controlling the illness, the nurse recognizes that a. all patients with elevated BP require medication. b. obese persons must achieve a normal weight to lower BP. c. it is not necessary to limit salt in the diet if taking a diuretic. d. lifestyle modifications are indicated for all persons with elevated BP.

d

The blood pressure of a 71-year-old patient admitted with pneumonia is 160/70 mm Hg. What is an age-related change that contributes to this finding? a. Stenosis of the heart valves Incorrect b. Decreased adrenergic sensitivity c. Increased parasympathetic activity d. Loss of elasticity in arterial vessels

d

What is included in the correct technique for BP measurements? a. Always take the BP in both arms. b. Position the patient supine for all readings. c. Place the cuff loosely around the upper arm. d. Take readings at least two times at least 1 minute apart.

d. Correct technique in measuring BP includes taking two or more readings at least 1 minute apart. Initially BP measurements should be taken in both arms to detect any differences. If there is a difference, the arm with the higher reading should be used for all subsequent BP readings. The patient may be supine or sitting. The important point is that the arm being used is at the heart level and the cuff needs to fit snugly.

What does the nursing responsibility in the management of the patient with hypertensive urgency often include? a. Monitoring hourly urine output for drug effectiveness b. Titrating IV drug dosages based on BP measurements every 2 to 3 minutes c. Providing continuous electrocardiographic (ECG) monitoring to detect side effects of the drugs d. Instructing the patient to follow up with a health care professional within 24 hours after outpatient treatment

d. Hypertensive urgencies are often treated with oral drugs on an outpatient basis but it is important for the patient to be seen by a health care professional within 24 hours to evaluate the effectiveness of the treatment. Hourly urine measurements, titration of IV drugs, and ECG monitoring are indicated for hypertensive emergencies.