Hypertension
10. A 42-year-old man has been diagnosed with primary hypertension with an average BP of 162/92 mm Hg on 3 consecutive clinic visits. What are 4 priority lifestyle modifications that should be explored in the initial treatment of the patient? 1. Dietary modifications to restrict sodium, cholesterol, and saturated fat; maintain intake of potassium, calcium, and magnesium; and promote weight reduction if overweight 2. Daily moderate-intensity physical activity for at least 30 minutes on most days of the week 3. Cessation of smoking (if a smoker) 4. Moderation or cessation of alcohol intake; usually medications and monitor BP at home. Also, psychosocial risk factors must be addressed.
1. Dietary modifications to restrict sodium, cholesterol, and saturated fat; maintain intake of potassium, calcium, and magnesium; and promote weight reduction if overweight 2. Daily moderate-intensity physical activity for at least 30 minutes on most days of the week 3. Cessation of smoking (if a smoker) 4. Moderation or cessation of alcohol intake; usually medications and monitor BP at home. Also, psychosocial risk factors must be addressed.
11. What is the primary BP effect of β-adrenergic blockers, such as atenolol (Tenormin)? a. Vasodilation of arterioles by blocking movement of calcium into cells b. Decrease Na+ and water reabsorption by blocking the effect of aldosterone c. Decrease CO by decreasing rate and strength of the heart and renin secretion by the kidneys d. Vasodilation caused by inhibiting sympathetic outflow from the central nervous system (CNS)
11. c. Cardioselective β-adrenergic blockers decrease CO, reduce sympathetic vasoconstrictor tone, and decrease renin secretion by kidneys. Calcium channel blockers reduce BP by causing blocked movement of calcium into cells, which causes vasodilation of arterioles. Spironolactone blocks the effect of aldosterone. Central adrenergic antagonists, such as clonidine (Catapres) inhibit sympathetic outflow from the central nervous system (CNS).
12. The patient asks the nurse about valsartan (Diovan), the new medication prescribed for blood pressure. What is the best explanation the nurse can use to explain the action of this medication? a. Prevents the conversion of angiotensin I to angiotensin II b. Acts directly on smooth muscle of arterioles to cause vasodilation c. Decreases extracellular fluid volume by increasing Na+ and Cl− excretion with water d. Vasodilation, prevents the action of angiotensin II, and promotes increased salt and water excretion
12. d. Valsartan (Diovan) is an angiotensin II receptor blocker (ARB). ARBs prevent the action of angiotensin II, produce vasodilation, and increase salt and water excretion. Angiotensin-converting enzyme (ACE) inhibitors prevent the conversion of angiotensin I to angiotensin II. Direct vasodilators act directly on smooth muscle of arterioles to cause vasodilation. Thiazide diuretics decrease extracellular fluid volume by increasing Na+ and Cl− excretion with water.
13. Dietary teaching that includes eating dietary sources of potassium is indicated for the hypertensive patient taking which drug? a. Enalapril b. Labetalol c. Spironolactone d. Hydrochlorothiazide
13. d. Hydrochlorothiazide is a thiazide diuretic that causes sodium and potassium loss through the kidneys. High-potassium foods should be included in the diet, or potassium supplements may be used to prevent hypokalemia. Enalapril and spironolactone may cause hyperkalemia by inhibiting the action of aldosterone, and potassium supplements should not be used by patients taking these drugs. As a combined α/β-blocker, labetalol does not affect potassium levels.
14. Priority Decision: A patient with stage 2 hypertension who is taking chlorothiazide (Diuril) and lisinopril (Zestril) has prazosin (Minipress) added to the medication regimen. What is most important for the nurse to teach the patient to do? a. Weigh every morning to monitor for fluid retention. b. Change position slowly and avoid prolonged standing. c. Use sugarless gum or candy to help relieve dry mouth. d. Take the pulse daily to note any slowing of the heart rate.
14. b. Chlorothiazide is a thiazide diuretic that causes orthostatic hypotension. Prazosin is an α-adrenergic blocker that causes dilation of arterioles and veins and causes orthostatic hypotension. The patient may feel dizzy, weak, and faint when assuming an upright position after sitting or lying down and should be taught to change positions slowly, avoid standing for long periods, do leg exercises to increase venous return, and lie or sit down when dizziness occurs. Direct-acting vasodilators often cause fluid retention; dry mouth may occur with diuretic use, and centrally acting α- and β-blockers may cause bradycardia.
15. A 38-year-old man is treated for hypertension with triamterene and hydrochlorothiazide and metoprolol (Lopressor). Four months after his last clinic visit, his BP returns to pretreatment levels, and he admits he has not been taking his medication regularly. What is the nurse's best response to this patient? a. "Try always to take your medication when you carry out another daily routine so that you do not forget to take it." b. "You probably would not need to take medications for hypertension if you would exercise more and stop smoking." c. "The drugs you are taking cause sexual dysfunction in many patients. Are you experiencing any problems in this area?" d. "You need to remember that hypertension can be only controlled with medication, not cured, and you must always take your medication."
15. c. Sexual dysfunction, which can occur with many of the antihypertensive drugs, including thiazide and potassium-sparing diuretics and β-adrenergic blockers, can be a major reason that a male patient does not adhere to his treatment regimen. It is helpful for the nurse to raise the subject because sexual problems may be easier for the patient to discuss and handle once it has been explained that the drug may be the source of the problem.
16. 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 baroreceptor reflexes c. Increased peripheral vascular resistance d. Increased adrenergic receptor sensitivity e. Increased collagen and stiffness of the myocardium f. Loss of elasticity in large arteries from arteriosclerosis
16. a, c, 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 baroreceptor reflexes are blunted. The adrenergic receptor sensitivity and renin response are both decreased with aging.
17. What should the nurse emphasize when teaching a patient who is newly prescribed clonidine (Catapres)? a. The drug should never be stopped abruptly. b. The drug should be taken early in the day to prevent nocturia. c. The first dose should be taken when the patient is in bed for the night. d. Because aspirin will decrease the drug's effectiveness, Tylenol should be used instead.
17. a. Centrally acting α-adrenergic blockers may cause severe rebound hypertension if the drugs are abruptly discontinued, and patients should be taught about this effect because many are not consistently compliant with drug therapy. Diuretics should be taken early in the day to prevent nocturia. The profound orthostatic hypotension that occurs with first-dose peripheral acting α-adrenergic blockers can be prevented by taking the initial dose at bedtime. Aspirin use may decrease the effectiveness of ACE inhibitors.
18. 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 2 times at least 1 minute apart.
18. d. Correct technique in measuring BP includes taking and averaging 2 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 points are that the arm being used is at the heart level and the cuff needs to fit snugly.
19. Collaboration: The unit is very busy and short staffed. What could the RN delegate to the unlicensed assistive personnel (UAP)? a. Administer antihypertensive medications to stable patients. b. Obtain orthostatic BP readings for older patients. c. Check BP readings for the patient receiving IV sodium nitroprusside. d. Teach about home BP monitoring and use of automatic BP monitoring equipment.
19. b. The UAP may check postural changes in BP as directed. The LPN may administer antihypertensive medications to stable patients. The RN must monitor the patient receiving IV sodium nitroprusside, as the patient is in a hypertensive crisis. The RN must also do the teaching related to home BP monitoring.
2. A patient is given an α1-adrenergic agonist and experiences a reflex bradycardia. What normal mechanism of BP control is stimulated in this situation?
2. The vasoconstriction caused by the α1-adrenergic agent raises the BP, stimulating the baroreceptors. The baroreceptors send impulses to the sympathetic vasomotor center in the brainstem, which inhibits the sympathetic nervous system, resulting in a decreased heart rate (HR), decreased force of contraction, and vasodilation.
20. Which manifestation is an indication that a patient is having hypertensive emergency? a. Symptoms of a stroke with an elevated BP b. A systolic BP (SBP) > 180 mm Hg and a diastolic BP (DBP) > 110 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
20. c. Hypertensive emergency, a type of hypertensive crisis, is a situation 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. Hypertensive crises are defined by the degree of organ damage and how rapidly the BP rises, not by specific BP measurements. A hypertensive urgency is a less severe crisis, in which a patient's BP becomes severely elevated over hours or days but there is no evidence of target organ damage.
21. Which drugs are most commonly used to treat hypertensive crises? a. Labetalol and bumetanide (Bumex) b. Esmolol (Brevibloc) and captopril (Captopril) c. Enalaprilat (Vasotec) and minoxidil (Minoxidil) d. Fenoldopam (Corlopam) and sodium nitroprusside (Nitropress)
21. d. Hypertensive crises are treated with IV administration of antihypertensive drugs, including the vasodilators sodium nitroprusside, fenoldopam, and nicardipine; adrenergic blockers, such as labetalol, esmolol, and phentolamine; the ACE inhibitor enalaprilat; the calcium channel blocker clevidipine; nitroglycerin for myocardial ischemia; hydralazine with other medications; and oral captopril. Sodium nitroprusside is the most effective parenteral drug for hypertensive emergencies.
22. A patient has a BP of 222/148 mm Hg and confusion, nausea, and vomiting. Which goal should the nurse try to achieve by titrating medications? 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. Decrease the SBP to 160 mm Hg and the DBP to 100 mm Hg as quickly as possible d. Reduce the SBP to 158 mm Hg and the DBP to 90 mm Hg within the first 2 hours
22. 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 222 + 2(148)/3 = 172, so decreasing it by 25% equals 129. Lowering the BP too far or too fast may cause a stroke, myocardial infarction (MI), or renal failure. Only when the patient has an aortic dissection, angina, or signs of an ischemic stroke does the SBP have to be lowered to 100 to 120 mm Hg or less as quickly as possible.
23. What does the nursing responsibility in the management of the patient with hypertensive urgency include? a. Monitoring hourly urine output for drug effectiveness b. Titrating IV drug dosages based on BP and HR 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 provider within 24 hours after outpatient treatment
23. 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 HCP within 24 hours to evaluate the effectiveness of the treatment. Hourly urine measurements, titration of IV drugs, and Electrocardiogram (ECG) monitoring are indicated for hypertensive emergencies.
3. A patient uses a mixed β-adrenergic blocking drug for treatment of migraine headaches. What effect may this drug have on BP and why?
3. The drug will lower BP because of decreased stroke volume and decreased HR, both of which decrease CO.
4. What are nonmodifiable risk factors for primary hypertension (select all that apply)? a. Age b. Obesity c. Gender d. Ethnicity e. Genetic link
4. a, c, d, e. Hypertension progresses with increasing age. It is more prevalent in men before early middle age and above the age of 64 years in women. Blacks have a higher incidence of hypertension than do whites. Children and siblings of patients with hypertension should be screened and taught about healthy lifestyles.
5. A patient diagnosed with secondary hypertension asks why it is called secondary and not primary. What is the best explanation for the nurse to provide? 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
5. c. Secondary hypertension has an underlying cause that will be treated, in contrast to primary or essential hypertension, which has no single known cause. Isolated systolic hypertension occurs when the systolic BP (SBP) is consistently equal to or over 130 mm Hg and the diastolic BP (DBP) is consistently equal to or over at 80 mm Hg.
6. What early manifestation(s) is the patient with primary hypertension likely to report? a. No symptoms b. Cardiac palpitations c. Dyspnea on exertion d. Dizziness and vertigo
6. a. Hypertension is often asymptomatic, especially if it is mild or moderate, and has been called the silent killer. The absence of symptoms often leads to noncompliance with medical treatment and a lack of concern about the disease in patients. With severe hypertension, symptoms may include fatigue, palpitations, angina, dyspnea, and dizziness.
7. What causes most organ damage in hypertension? a. Increased fluid pressure exerted against organ tissue b. Atherosclerotic changes in vessels that supply the organs c. Erosion and thinning of blood vessels in organs from constant pressure d. Increased hydrostatic pressure causing leakage of plasma into organ interstitial spaces
7. b. Elevated BP causes endothelial damage, which causes the inner lining of arterioles to become thickened and stiffened and affects coronary circulation, cerebral circulation, peripheral vessels, and renal and retinal blood vessels. The narrowed vessels lead to ischemia and ultimately to damage of these organs.
8. 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. Heart c. Retina d. Kidney
8. b. 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. The heart may be indirectly damaged by atherosclerotic changes in the blood vessels, as are the brain, retina, and kidney.
The nurse obtains a blood pressure of 176/82 mm Hg for a patient. What is the patient's mean arterial pressure (MAP)?
ANS: 113 mm Hg MAP = (SBP + 2 DBP)/3
The charge nurse observes a new registered nurse (RN) doing discharge teaching for a patient with hypertension who has a new prescription for enalapril (Vasotec). The charge nurse will need to intervene if the new RN tells the patient to a. increase the dietary intake of high-potassium foods. b. make an appointment with the dietitian for teaching. c. check the blood pressure (BP) at home at least once a day. d. move slowly when moving from lying to sitting to standing.
ANS: A The ACE inhibitors cause retention of potassium by the kidney, so hyperkalemia is a possible adverse effect. The other teaching by the new RN is appropriate for a patient with newly diagnosed hypertension who has just started therapy with enalapril
The nurse is reviewing the laboratory test results for a patient who has recently been diagnosed with hypertension. Which result is most important to communicate to the health care provider? a. Serum creatinine of 2.8 mg/dL b. Serum potassium of 4.5 mEq/L c. Serum hemoglobin of 14.7 g/dL d. Blood glucose level of 96 mg/dL
ANS: A The elevated serum creatinine indicates renal damage caused by the hypertension. The other laboratory results are normal.
Which nursing action should the nurse take first to assist a patient with newly diagnosed stage 1 hypertension in making needed dietary changes? a. Collect a detailed diet history. b. Provide a list of low-sodium foods. c. Help the patient make an appointment with a dietitian. d. Teach the patient about foods that are high in potassium.
ANS: A The initial nursing action should be assessment of the patient's baseline dietary intake through a thorough diet history. The other actions may be appropriate, but assessment of the patient's baseline should occur first.
The nurse on the intermediate care unit received change-of-shift report on four patients with hypertension. Which patient should the nurse assess first? a. 48-yr-old with a blood pressure of 160/92 mm Hg who reports chest pain b. 52-yr-old with a blood pressure of 198/90 mm Hg who has intermittent claudication c. 50-yr-old with a blood pressure of 190/104 mm Hg who has a creatinine of 1.7 mg/dL d. 43-yr-old with a blood pressure of 172/98 mm Hg whose urine shows microalbuminuria
ANS: A The patient with chest pain may be experiencing acute myocardial infarction and rapid assessment and intervention are needed. The symptoms of the other patients also show target organ damage but are not indicative of acute processes.
The nurse has just finished teaching a hypertensive patient about the newly prescribed drug, ramipril (Altace). Which patient statement indicates that more teaching is needed? a. "The medication may not work well if I take aspirin." b. "I can expect some swelling around my lips and face." c. "The doctor may order a blood potassium level occasionally." d. "I will call the doctor if I notice that I have a frequent cough."
ANS: B Angioedema occurring with angiotensin-converting enzyme (ACE) inhibitor therapy is an indication that the ACE inhibitor should be discontinued. The patient should be taught that if any swelling of the face or oral mucosa occurs, the health care provider should be immediately notified because this could be life threatening. The other patient statements indicate that the patient has an accurate understanding of ACE inhibitor therapy
A patient with hypertension who has just started taking atenolol (Tenormin) returns to the health clinic after 2 weeks for a follow-up visit. The blood pressure (BP) is unchanged from the previous visit. Which action should the nurse take first? a. Tell the patient why a change in drug dosage is needed. b. Ask the patient if the medication is being taken as prescribed. c. Inform the patient that multiple drugs are often needed to treat hypertension. d. Question the patient regarding any lifestyle changes made to help control BP.
ANS: B Because nonadherence with antihypertensive therapy is common, the nurse's initial action should be to determine whether the patient is taking the atenolol as prescribed. The other actions also may be implemented, but these would be done after assessing patient adherence with the prescribed therapy.
Which assessment finding for a patient who is receiving IV furosemide (Lasix) to treat stage 2 hypertension is most important to report to the health care provider? a. Blood glucose level of 175 mg/dL b. Serum potassium level of 3.0 mEq/L c. Orthostatic systolic BP decrease of 12 mm Hg d. Most recent blood pressure (BP) reading of 168/94 mm Hg
ANS: B Hypokalemia is a frequent adverse effect of the loop diuretics and can cause life-threatening dysrhythmias. The health care provider should be notified of the potassium level immediately and administration of potassium supplements initiated. The elevated blood glucose and BP also indicate a need for collaborative interventions but will not require action as urgently as the hypokalemia. An orthostatic drop of 12 mm Hg will require intervention only if the patient is symptomatic.
An older patient has been diagnosed with possible white coat hypertension. Which planned action by the nurse best addresses the suspected cause of the hypertension? a. Instruct the patient about the need to decrease stress levels. b. Teach the patient how to self-monitor and record BPs at home. c. Schedule the patient for regular blood pressure (BP) checks in the clinic. d. Inform the patient and caregiver that major dietary changes will be needed.
ANS: B In the phenomenon of "white coat" hypertension, patients have elevated BP readings in a clinical setting and normal readings when BP is measured elsewhere. Having the patient self-monitor BPs at home will provide a reliable indication about whether the patient has hypertension. Regular BP checks in the clinic are likely to be high in a patient with white coat hypertension. There is no evidence that this patient has elevated stress levels or a poor diet, and those factors do not cause white coat hypertension.
A patient with a history of hypertension treated with a diuretic and an angiotensin-converting enzyme (ACE) inhibitor arrives in the emergency department complaining of a severe headache and nausea and has a blood pressure (BP) of 238/118 mm Hg. Which question should the nurse ask to follow up on these findings? a. "Have you recently taken any antihistamines?" b. "Have you consistently taken your medications?" c. "Did you take any acetaminophen (Tylenol) today?" d. "Have there been recent stressful events in your life?"
ANS: B Sudden withdrawal of antihypertensive medications can cause rebound hypertension and hypertensive crisis. Although many over-the-counter medications can cause hypertension, antihistamines and acetaminophen do not increase BP. Stressful events will increase BP but not usually to the level seen in this patient.
Which blood pressure (BP) finding by the nurse indicates that no changes in therapy are needed for a 48-yr-old patient with newly diagnosed hypertension? a. 98/56 mm Hg b. 128/76 mm Hg c. 128/92 mm Hg d. 142/78 mm Hg
ANS: B The 8th Joint National Committee's recommended goal for antihypertensive therapy for a 30- to 59-yr-old patient with hypertension is a BP below 140/90 mm Hg. The BP of 98/56 mm Hg may indicate overtreatment of the hypertension and an increased risk for adverse drug effects. The other two blood pressures indicate a need for modifications in the patient's treatment.
Which action will the nurse in the hypertension clinic take to obtain an accurate baseline blood pressure (BP) for a new patient? a. Deflate the BP cuff at a rate of 5 to 10 mm Hg per second. b. Have the patient sit in a chair with the feet flat on the floor. c. Assist the patient to the supine position for BP measurements. d. Obtain two BP readings in the dominant arm and average the results.
ANS: B The patient should be seated with the feet flat on the floor. The BP is obtained in both arms, and the results of the two arms are not averaged. The patient does not need to be in the supine position. The cuff should be deflated at 2 to 3 mm Hg per second.
The nurse is assessing a patient who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider? a. Urine output over 8 hours is 250 mL less than the fluid intake. b. The patient cannot move the left arm and leg when asked to do so. c. Tremors are noted in the fingers when the patient extends the arms. d. The patient complains of a headache with pain at level 7 of 10 (0 to 10 scale).
ANS: B The patient's inability to move the left arm and leg indicates that a stroke may be occurring and will require immediate action to prevent further neurologic damage. The other clinical manifestations are also likely caused by the hypertension and will require rapid nursing actions, but they do not require action as urgently as the neurologic changes.
The nurse obtains the following information from a patient newly diagnosed with prehypertension. Which finding is most important to address with the patient? a. Low dietary fiber intake b. No regular physical exercise c. Drinks a beer with dinner every night d. Weight is 5 pounds above ideal weight
ANS: B The recommendations for preventing hypertension include exercising aerobically for 30 minutes most days of the week. A weight that is 5 pounds over the ideal body weight is not a risk factor for hypertension. The Dietary Approaches to Stop Hypertension (DASH) diet is high in fiber, but increasing fiber alone will not prevent hypertension from developing. The patient's alcohol intake is within guidelines and will not increase the hypertension risk.
A 56-yr-old patient who has no previous history of hypertension or other health problems suddenly develops a blood pressure (BP) of 198/110 mm Hg. After reconfirming the BP, it is appropriate for the nurse to tell the patient that a. a BP recheck should be scheduled in a few weeks. b. dietary sodium and fat content should be decreased. c. diagnosis, treatment, and ongoing monitoring will be needed. d. there is an immediate danger of a stroke, requiring hospitalization.
ANS: C A sudden increase in BP in a patient older than age 50 years with no previous hypertension history or risk factors indicates that the hypertension may be secondary to some other problem. The BP will need treatment and ongoing monitoring. If the patient has no other risk factors, a stroke in the immediate future is unlikely. There is no indication that dietary salt or fat intake have contributed to this sudden increase in BP, and reducing intake of salt and fat alone will not be adequate to reduce this BP to an acceptable level.
After the nurse teaches the patient with stage 1 hypertension about diet modifications that should be implemented, which diet choice indicates that the teaching has been most effective? a. The patient avoids eating nuts or nut butters. b. The patient restricts intake of chicken and fish. c. The patient drinks low-fat milk with each meal. d. The patient has two cups of coffee in the morning.
ANS: C For the prevention of hypertension, the Dietary Approaches to Stop Hypertension (DASH) recommendations include increasing the intake of calcium-rich foods. Caffeine restriction and decreased protein intake are not included in the recommendations. Nuts are high in beneficial nutrients and 4 to 5 servings weekly are recommended in the DASH diet.
Which information is most important for the nurse to include when teaching a patient with newly diagnosed hypertension? a. Most people are able to control BP through dietary changes. b. Annual BP checks are needed to monitor treatment effectiveness. c. Hypertension is usually asymptomatic until target organ damage occurs. d. Increasing physical activity alone controls blood pressure (BP) for most people.
ANS: C Hypertension is usually asymptomatic until target organ damage has occurred. Lifestyle changes (e.g., physical activity, dietary changes) are used to help manage BP, but drugs are needed for most patients. Home BP monitoring should be taught to the patient and findings checked by the health care provider frequently when starting treatment for hypertension and then every 3 months when stable.
Propranolol (Inderal) is prescribed for a patient diagnosed with hypertension. The nurse should consult with the health care provider before giving this drug when the patient reveals a history of a. daily alcohol use. b. peptic ulcer disease. c. reactive airway disease. d. myocardial infarction (MI).
ANS: C Nonselective b-blockers block b1 and b2-adrenergic receptors and can cause bronchospasm, especially in patients with a history of asthma. B-Blockers will have no effect on the patient's peptic ulcer disease or alcohol use. B-Blocker therapy is recommended after MI.
A patient has just been diagnosed with hypertension and has been started on captopril . Which information is most important to include when teaching the patient about this drug? a. Include high-potassium foods such as bananas in the diet. b. Increase fluid intake if dryness of the mouth is a problem. c. Change position slowly to help prevent dizziness and falls. d. Check blood pressure (BP) in both arms before taking the drug.
ANS: C The angiotensin-converting enzyme (ACE) inhibitors frequently cause orthostatic hypotension, and patients should be taught to change position slowly to allow the vascular system time to compensate for the position change. Increasing fluid intake may counteract the effect of the drug, and the patient is taught to use gum or hard candy to relieve dry mouth. The BP should be taken in the nondominant arm by newly diagnosed patients in the morning, before taking the drug, and in the evening. Because ACE inhibitors cause potassium retention, increased intake of high-potassium foods is inappropriate.
During change-of-shift report, the nurse obtains the following information about a hypertensive patient who received the first dose of nadolol (Corgard) during the previous shift. Which information indicates that the patient needs immediate intervention? a. The patient's pulse has dropped from 68 to 57 beats/min. b. The patient complains that the fingers and toes feel quite cold. c. The patient has developed wheezes throughout the lung fields. d. The patient's blood pressure (BP) reading is now 158/91 mm Hg.
ANS: C The most urgent concern for this patient is the wheezes, which indicate that bronchospasm (a common adverse effect of the noncardioselective b-blockers) is occurring. The nurse should immediately obtain an O2 saturation measurement, apply supplemental O2, and notify the health care provider. The mild decrease in heart rate and complaint of cold fingers and toes are associated with b-receptor blockade but do not require any change in therapy. The BP reading may indicate that a change in medication type or dose may be indicated. However, this is not as urgently needed as addressing the bronchospasm.
The nurse is caring for a 70-yr-old patient who uses hydrochlorothiazide and enalapril (Norvasc) but whose self-monitored blood pressure (BP) continues to be elevated. Which patient information may indicate a need for a change? a. Patient takes a daily multivitamin tablet. b. Patient checks BP daily just after getting up. c. Patient drinks wine three to four times a week. d. Patient uses ibuprofen (Motrin) treat osteoarthritis.
ANS: D Because use of nonsteroidal antiinflammatory drugs (NSAIDs) can prevent adequate BP control, the patient may need to avoid the use of ibuprofen. A multivitamin tablet will help supply vitamin D, which may help lower BP. BP decreases while sleeping, so self-monitoring early in the morning will result in obtaining pressures that are at their lowest. The patient's alcohol intake is not excessive.
Which action will be included in the plan of care when the nurse is caring for a patient who is receiving nicardipine (Cardene) to treat a hypertensive emergency? a. Organize nursing activities so that the patient has undisturbed sleep for 8 hours at night. b. Keep the patient NPO to prevent aspiration caused by nausea and possible vomiting. c. Assist the patient up in the chair for meals to avoid complications associated with immobility. d. Use an automated noninvasive blood pressure machine to obtain frequent measurements.
ANS: D Frequent monitoring of BP is needed when the patient is receiving rapid-acting IV antihypertensive medications. This can be most easily accomplished with an automated BP machine or arterial line. The patient will require frequent assessments, so allowing 8 hours of undisturbed sleep is not reasonable. When patients are receiving IV vasodilators, bed rest is maintained to prevent decreased cerebral perfusion and fainting. There is no indication that this patient is nauseated or at risk for aspiration, so an NPO status is unnecessary.
The registered nurse (RN) is caring for a patient with a hypertensive crisis who is receiving sodium nitroprusside . Which nursing action can the nurse delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Evaluate effectiveness of nitroprusside therapy on blood pressure (BP). b. Assess the patient's environment for adverse stimuli that might increase BP. c. Titrate nitroprusside to decrease mean arterial pressure (MAP) to 115 mm Hg. d. Set up the automatic noninvasive BP machine to take readings every 15 minutes.
ANS: D LPN/LVN education and scope of practice include the correct use of common equipment such as automatic noninvasive blood pressure machines. The other actions require advanced nursing judgment and education, and should be done by RNs.
Which action should the nurse take when giving the initial dose of oral labetalol to a patient with hypertension? a. Encourage the use of hard candy to prevent dry mouth. b. Teach the patient that headaches often occur with this drug. c. Instruct the patient to call for help if heart palpitations occur. d. Ask the patient to request assistance before getting out of bed.
ANS: D Labetalol decreases sympathetic nervous system activity by blocking both alpha and beta-adrenergic receptors, leading to vasodilation and a decrease in heart rate, which can cause severe orthostatic hypotension. Heart palpitations, dry mouth, dehydration, and headaches are possible side effects of other antihypertensives.
9. Identify the significance of the following laboratory study results when found in patients with hypertension. BUN: 48mg/dL (17.1 mmol/L) Serum K+: 3.1mEq/L (3.1 mmol/L) Serum uric acid: 9.2 mg/dL (547 mmol/L) Fasting blood glucose: 183 mg/dL (10.2 mmol/L) Low-density lipoproteins (LDL): 154 mg/dL (4.0 mmol/L)
BUN - Elevated BUN and creatinine may indicate destruction of glomeruli and tubules of the kidney resulting from hypertension. Serum K+ - Serum potassium levels are decreased when hypertension is associated with hyperaldosteronism. Serum Uric Acid - An increased uric acid level may be caused by diuretics used to treat hypertension. Fasting Blood Glucose - Fasting glucose levels are elevated when hypertension is associated with glucose intolerance and insulin resistance. LDL - An elevated LDL level indicates an increased risk for atherosclerotic changes in the patient with hypertension.
1. In the regulation of normal blood pressure (BP), indicate whether the following mechanisms elevate BP by: increasing cardiac output (CO), increasing systemic vascular resistance (SVR), or increasing both, and identify how these mechanisms cause the increase. beta1 adrenergic stimulation alpha1 adrenergic stimulation alpha2 adrenergic stimulation endothelin release AII aldosterone release ADH release
beta1 adrenergic stimulation 1x 2x - increased rate and contractility of the heart increases CO - peripheral artery vasoconstriction - stimulation of renin production that activates RAAS alpha1 adrenergic stimulation 1x 2x - peripheral arteriole vasoconstriction and increased contractility of the heart alpha2 adrenergic stimulation 2x - constriction of selected vascular beds endothelin release 2x - vasoconstriction AII 2x - arteriole vasoconstriction aldosterone release 1x - increased vascular volume ADH release 1x - increased vascular volume