Chapter 27

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.

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 Rationale: 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.

In caring for a patient admitted with poorly controlled hypertension, which laboratory test result should the nurse understand as indicating the presence of target organ damage? Serum uric acid of 3.8 mg/dL Serum creatinine of 2.6 mg/dL Serum potassium of 3.5 mEq/L Blood urea nitrogen of 15 mg/dL

Serum creatinine of 2.6 mg/dL Rationale: The normal serum creatinine level is 0.6 to 1.3 mg/dL. This elevated level indicates target organ damage to the kidneys. The other laboratory results are within normal limits.

Identify the significance of the following laboratory study results when found in patients with hypertension. Laboratory Studies a. Blood urea nitrogen (BUN): 48 mg/dL (17.1 mmol/L) Creatinine: 4.3 mg/dL (380 mmol/L) b. Serum K+: 3.1 mEq/L (3.1 mmol/L) c. Serum uric acid: 9.2 mg/dL (547 mmol/L) d. Fasting blood glucose: 183 mg/dL (10.2 mmol/L) e. Low-density lipoproteins (LDL): 154 mg/dL (4.0 mmol/L)

Significance a. Elevated BUN and creatinine may indicate destruction of glomeruli and tubules of the kidney resulting from hypertension. b. Serum potassium levels are decreased when hypertension is associated with hyperaldosteronism. c. An increased uric acid level may be caused by diuretics used to treat hypertension. d. Fasting glucose levels are elevated when hypertension is associated with glucose intolerance and insulin resistance. e. An elevated LDL level indicates an increased risk for atherosclerotic changes in the patient with hypertension.

A 67-yr-old woman with hypertension is admitted to the emergency department with a blood pressure of 234/148 mm Hg and was started on nitroprusside (Nitropress). After 1 hour of treatment, the mean arterial blood pressure (MAP) is 55 mm Hg. Which nursing action is a priority? Start an infusion of 0.9% normal saline at 100 mL/hr. Maintain the current administration rate of the nitroprusside. Request insertion of an arterial line for accurate blood pressure monitoring. Stop the nitroprusside infusion and assess the patient for potential complications.

Stop the nitroprusside infusion and assess the patient for potential complications. Rationale: Nitroprusside is a potent vasodilator medication. A blood pressure of 234/118 mm Hg would have a calculated MAP of 177 mm Hg. Subtracting 25% (or 44 mm Hg) = 133 mm Hg. The initial treatment goal is to decrease MAP by no more than 25% within minutes to 1 hour. For this patient, the goal MAP would be around 133 mm Hg. Minimal MAP required to perfuse organs is around 60 to 65 mm Hg. Lowering the blood pressure too rapidly may decrease cerebral, coronary, or renal perfusion and could precipitate a stroke, myocardial infarction, or renal failure. The priority is to stop the nitroprusside infusion and then use fluids only if necessary to support restoration of MAP.

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.

A 44-yr-old man is diagnosed with hypertension and receives a prescription for benazepril (Lotensin). After providing teaching, which statement by the patient indicates correct understanding? "If I take this medication, I will not need to follow a special diet." "It is normal to have some swelling in my face while taking this medication." "I will need to eat foods such as bananas and potatoes that are high in potassium." "If I develop a dry cough while taking this medication, I should notify my doctor."

"If I develop a dry cough while taking this medication, I should notify my doctor." Rationale: Benazepril is an angiotensin-converting enzyme inhibitor. The medication inhibits breakdown of bradykinin, which may cause a dry, hacking cough. Other adverse effects include hyperkalemia. Swelling in the face could indicate angioedema and should be reported immediately to the prescriber. Patients taking drug therapy for hypertension should also attempt lifestyle modifications to lower blood pressure such as a reduced sodium diet.

39. A patient's medication regimen for the treatment of hypertension includes hydrochlorothiazide. Following administration of this medication, the nurse should anticipate what effect? A) Drowsiness or lethargy B) Increased urine output C) Decreased heart rate D) Mild agitation

Ans: B Feedback: Thiazide diuretics lower BP by reducing circulating blood volume; this results in a short-term increase in urine output. These drugs do not cause bradycardia, agitation, or drowsiness.

CASE STUDY: Primary Hypertension Patient Profile K.J. is a 66-year-old black woman with no history of hypertension. She came to the doctor's office for a flu shot. Subjective Data • Says she has gained 20 lb over the past year since her husband died • Has never smoked and uses no alcohol • Only medication is 1 multivitamin per day • Eats a lot of canned food • Does not exercise Objective Data • Height: 5 ft 4 in (162.6 cm) • Weight: 180 lb (77.1 kg) • BP: 170/86 mm Hg • Physical examination shows no abnormalities • Serum potassium: 3.3 mEq/L (3.3 mmol/L) - The health care provider diagnosed hypertension, stage 2 and prescribed lifestyle modifications. Discussion Questions : 1. What contributing factors to the development of hypertension, stage 2 are present in K.J.? 2. What additional risk factors are present? 3. Patient-Centered Care: What specific dietary change would the nurse recommend for K.J.? 4. If drug therapy became necessary to treat K.J.'s hypertension, what diuretic would be indicated based on her laboratory results? 5. Collaboration: What referrals may help K.J. with managing her hypertension? 6. Priority Decision: What other priority teaching measures should be instituted by the nurse? 7. Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses? Are there any collaborative problems?

1. Increasing age, which leads to loss of elasticity in large arteries from atherosclerosis, increased collagen content and stiffness of the myocardium, increased peripheral vascular resistance, decreased adrenergic receptor sensitivity, blunting of baroreceptor reflexes, decreased renal function, and decreased renin response. At 73 years, there is also a higher prevalence in women. She is also black. 2. High sodium intake from canned foods, sedentary lifestyle, and weight gain 3. The Dietary Approaches to Stop Hypertension (DASH) eating plan is rich in fresh or frozen fruits and vegetables, fat-free or low-fat milk, whole grains, fish, poultry, beans, seeds, and nuts. In this eating plan, there are less salt and sodium, less sweets, less fat, and less red meat than in the typical American diet. Increasing activity and losing weight (if necessary) is encouraged. Increasing calcium, vitamin D, omega-3 fatty acids, potassium, and fiber are also recommended. 4. Because of K.J.'s low potassium level, a potassium-sparing diuretic, such as amiloride, triamterene, or spironolactone, could be used. If a stronger diuretic was needed, potassium supplementation would be indicated. If an ACE inhibitor was also needed, the diuretic would need to be changed related to additional potassium-sparing. 5. A referral to a dietitian for assistance in changing her diet; a referral to a physical therapist for safely increasing her physical activity; and referral to a grief counselor could all benefit K.J. 6. The nurse should teach K.J. about regular daily aerobic exercise and weight reduction; avoiding canned food and reading labels for sodium content; the need for grief management indicated by weight gain in response to her husband's death and availability of counseling; the pathology, complications, and management of hypertension; and medications if ordered and the potential of orthostatic hypotension. 7. Nursing diagnoses • Electrolyte imbalance; Etiology: increased caloric intake and deficiency of potassium sources • Difficulty coping; Etiology: use of food as coping mechanism • Lack of knowledge; Etiology: lack of knowledge of pathology, complications, and management of hypertension and treatment • Altered blood pressure; Etiology: hypertension management and treatment Collaborative problems Potential complications: cerebrovascular accident, MI, renal failure, retinopathy

A female patient with chronic hypertension is admitted to the emergency department with a sudden rise in BP. Which question is the priority for the nurse to ask the patient?

A) "Do you have a headache or confusion?"

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 -blockers block 1- and 2-adrenergic receptors and can cause bronchospasm, especially in patients with a history of asthma. -Blockers will have no effect on the patient's peptic ulcer disease or alcohol use. -Blocker therapy is recommended after MI.

32. A community health nurse is planning an educational campaign addressing hypertension. The nurse should anticipate that the incidence and prevalence of hypertension are likely to be highest among members of what ethnic group? A) Pacific Islanders B) African Americans C) Asian-Americans D) Hispanics

Ans: D Feedback: The prevalence of uncontrolled hypertension varies by ethnicity, with Hispanics and African Americans having the highest prevalence at approximately 63% and 57%, respectively.

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 -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 -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 - and -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.

2. A patient with primary hypertension comes to the clinic complaining of a gradual onset of blurry vision and decreased visual acuity over the past several weeks. The nurse is aware that these symptoms could be indicative of what? A) Retinal blood vessel damage B) Glaucoma C) Cranial nerve damage D) Hypertensive emergency

Ans: A Feedback: Blurred vision, spots in front of the eyes, and diminished visual acuity can mean retinal blood vessel damage indicative of damage elsewhere in the vascular system as a result of hypertension. Glaucoma and cranial nerve damage do not normally cause these symptoms. A hypertensive emergency would have a more rapid onset.

20. The nurse is developing a nursing care plan for a patient who is being treated for hypertension. What is a measurable patient outcome that the nurse should include? A) Patient will reduce Na+ intake to no more than 2.4 g daily. B) Patient will have a stable BUN and serum creatinine levels. C) Patient will abstain from fat intake and reduce calorie intake. D) Patient will maintain a normal body weight.

Ans: A Feedback: Dietary sodium intake of no more than 2.4 g sodium is recommended as a dietary lifestyle modification to prevent and manage hypertension. Giving a specific amount of allowable sodium intake makes this a measurable goal. None of the other listed goals is quantifiable and measurable.

14. A nurse is teaching an adult female patient about the risk factors for hypertension. What should the nurse explain as risk factors for primary hypertension? A) Obesity and high intake of sodium and saturated fat B) Diabetes and use of oral contraceptives C) Metabolic syndrome and smoking D) Renal disease and coarctation of the aorta

Ans: A Feedback: Obesity, stress, high intake of sodium or saturated fat, and family history are all risk factors for primary hypertension. Diabetes and oral contraceptives are risk factors for secondary hypertension. Metabolic syndrome, renal disease, and coarctation of the aorta are causes of secondary hypertension.

10. A patient with primary hypertension complains of dizziness with ambulation. The patient is currently on an alpha-adrenergic blocker and the nurse assesses characteristic signs and symptoms of postural hypotension. When teaching this patient about risks associated with postural hypotension, what should the nurse emphasize? A) Rising slowly from a lying or sitting position B) Increasing fluids to maintain BP C) Stopping medication if dizziness persists D) Taking medication first thing in the morning

Ans: A Feedback: Patients who experience postural hypotension should be taught to rise slowly from a lying or sitting position and use a cane or walker if necessary for safety. It is not necessary to teach these patients about increasing fluids or taking medication in the morning (this would increase the effects of dizziness). Patient should not be taught to stop the medication if dizziness persists because this is unsafe and beyond the nurse's scope of practice.

18. A patient has come to the clinic for a follow-up assessment that will include a BP reading. To ensure an accurate reading, the nurse should confirm that the patient has done which of the following? A) Tried to rest quietly for 5 minutes before the reading is taken B) Refrained from smoking for at least 8 hours C) Drunk adequate fluids during the day prior D) Avoided drinking coffee for 12 hours before the visit

Ans: A Feedback: Prior to the nurse assessing the patient's BP, the patient should try to rest quietly for 5 minutes. The forearm should be positioned at heart level. Caffeine products and cigarette smoking should be avoided for at least 30 minutes prior to the visit. Recent fluid intake is not normally relevant.

16. A patient with secondary hypertension has come into the clinic for a routine check-up. The nurse is aware that the difference between primary hypertension and secondary hypertension is which of the following? A) Secondary hypertension has a specific cause. B) Secondary hypertension has a more gradual onset than primary hypertension. C) Secondary hypertension does not cause target organ damage. D) Secondary hypertension does not normally respond to antihypertensive drug therapy.

Ans: A Feedback: Secondary hypertension has a specific identified cause. A cause could include narrowing of the renal arteries, renal parenchymal disease, hyperaldosteronism, certain medications, pregnancy, and coarctation of the aorta. Secondary hypertension does respond to antihypertensive drug therapy and can cause target organ damage if left untreated.

7. A patient has been prescribed antihypertensives. After assessment and analysis, the nurse has identified a nursing diagnosis of risk for ineffective health maintenance related to nonadherence to therapeutic regimen. When planning this patient's care, what desired outcome should the nurse identify? A) Patient takes medication as prescribed and reports any adverse effects. B) Patient's BP remains consistently below 140/90 mm Hg. C) Patient denies signs and symptoms of hypertensive urgency. D) Patient is able to describe modifiable risk factors for hypertension.

Ans: A Feedback: The most appropriate expected outcome for a patient who is given the nursing diagnosis of risk for ineffective health maintenance is that he or she takes the medication as prescribed. The other listed goals are valid aspects of care, but none directly relates to the patient's role in his or her treatment regimen.

9. A patient newly diagnosed with hypertension asks the nurse what happens when uncontrolled hypertension is prolonged. The nurse explains that a patient with prolonged, uncontrolled hypertension is at risk for developing what health problem? A) Renal failure B) Right ventricular hypertrophy C) Glaucoma D) Anemia

Ans: A Feedback: When uncontrolled hypertension is prolonged, it can result in renal failure, myocardial infarction, stroke, impaired vision, left ventricular hypertrophy, and cardiac failure. Glaucoma and anemia are not directly associated with hypertension.

8. The nurse is providing care for a patient with a new diagnosis of hypertension. How can the nurse best promote the patient's adherence to the prescribed therapeutic regimen? A) Screen the patient for visual disturbances regularly. B) Have the patient participate in monitoring his or her own BP. C) Emphasize the dire health outcomes associated with inadequate BP control. D) Encourage the patient to lose weight and exercise regularly.

Ans: B Feedback: Adherence to the therapeutic regimen increases when patients actively participate in self-care, including self-monitoring of BP and diet. Dire warnings may motivate some patients, but for many patients this is not an appropriate or effective strategy. Screening for vision changes and promoting healthy lifestyle are appropriate nursing actions, but do not necessarily promote adherence to a therapeutic regimen.

13. The nursing lab instructor is teaching student nurses how to take blood pressure. To ensure accurate measurement, the lab instructor would teach the students to avoid which of the following actions? A) Measuring the BP after the patient has been seated quietly for more than 5 minutes B) Taking the BP at least 10 minutes after nicotine or coffee ingestion C) Using a cuff with a bladder that encircles at least 80% of the limb D) Using a bare forearm supported at heart level on a firm surface

Ans: B Feedback: Blood pressures should be taken with the patient seated with arm bare, supported, and at heart level. The patient should not have smoked tobacco or taken caffeine in the 30 minutes preceding the measurement. The patient should rest quietly for 5 minutes before the reading is taken. The cuff bladder should encircle at least 80% of the limb being measured and have a width of at least 40% of limb circumference. Using a cuff that is too large results in a lower BP and a cuff that is too small will give a higher BP measurement.

22. The hospital nurse cares for many patients who have hypertension. What nursing diagnosis is most common among patients who are being treated for this health problem? A) Deficient knowledge regarding the lifestyle modifications for management of hypertension B) Noncompliance with therapeutic regimen related to adverse effects of prescribed therapy C) Deficient knowledge regarding BP monitoring D) Noncompliance with treatment regimen related to medication costs

Ans: B Feedback: Deviation from the therapeutic program is a significant problem for people with hypertension and other chronic conditions requiring lifetime management. For many patients, this is related to adverse effects of medications. Medication cost is relevant for many patients, but adverse effects are thought to be a more significant barrier. Many patients are aware of necessary lifestyle modification, but do not adhere to them. Most patients are aware of the need to monitor their BP.

15. The nurse is caring for an older adult with a diagnosis of hypertension who is being treated with a diuretic and beta-blocker. Which of the following should the nurse integrate into the management of this client's hypertension? A) Ensure that the patient receives a larger initial dose of antihypertensive medication due to impaired absorption. B) Pay close attention to hydration status because of increased sensitivity to extracellular volume depletion. C) Recognize that an older adult is less likely to adhere to his or her medication regimen than a younger patient. D) Carefully assess for weight loss because of impaired kidney function resulting from normal aging.

Ans: B Feedback: Elderly people have impaired cardiovascular reflexes and thus are more sensitive to extracellular volume depletion caused by diuretics. The nurse needs to assess hydration status, low BP, and postural hypotension carefully. Older adults may have impaired absorption, but they do not need a higher initial dose of an antihypertensive than a younger person. Adherence to treatment is not necessarily linked to age. Kidney function and absorption decline with age; less, rather than more antihypertensive medication is prescribed. Weight gain is not necessarily indicative of kidney function decline.

27. During an adult patient's last two office visits, the nurse obtained BP readings of 122/84 mm Hg and 130/88 mm Hg, respectively. How would this patient's BP be categorized? A) Normal B) Prehypertensive C) Stage 1 hypertensive D) Stage 2 hypertensive

Ans: B Feedback: Prehypertension is defined systolic BP of 120 to 139 mm Hg or diastolic BP of 80 to 89 mm Hg.

6. A 40-year-old male newly diagnosed with hypertension is discussing risk factors with the nurse. The nurse talks about lifestyle changes with the patient and advises that the patient should avoid tobacco use. What is the primary rationale behind that advice to the patient? A) Quitting smoking will cause the patient's hypertension to resolve. B) Tobacco use increases the patient's concurrent risk of heart disease. C) Tobacco use is associated with a sedentary lifestyle. D) Tobacco use causes ventricular hypertrophy.

Ans: B Feedback: Smoking increases the risk for heart disease, for which a patient with hypertension is already at an increased risk. Quitting will not necessarily cause hypertension to resolve and smoking does not directly cause ventricular hypertrophy. The association with a sedentary lifestyle is true, but this is not the main rationale for the nurse's advice; the association with heart disease is more salient.

29. A patient has been diagnosed as being prehypertensive. What should the nurse encourage this patient to do to aid in preventing a progression to a hypertensive state? A) Avoid excessive potassium intake. B) Exercise on a regular basis. C) Eat less protein and more vegetables. D) Limit morning activity.

Ans: B Feedback: To prevent or delay progression to hypertension and reduce risk, JNC 7 urged health care providers to encourage people with blood pressures in the prehypertension category to begin lifestyle modifications, such as nutritional changes and exercise. There is no need for patients to limit their activity in the morning or to avoid potassium and protein intake.

17. The nurse is assessing a patient new to the clinic. Records brought to the clinic with the patient show the patient has hypertension and that her current BP readings approximate the readings from when she was first diagnosed. What contributing factor should the nurse first explore in an effort to identify the cause of the client's inadequate BP control? A) Progressive target organ damage B) Possibility of medication interactions C) Lack of adherence to prescribed drug therapy D) Possible heavy alcohol use or use of recreational drugs

Ans: C Feedback: Deviation from the therapeutic program is a significant problem for people with hypertension and other chronic conditions requiring lifetime management. An estimated 50% of patients discontinue their medications within 1 year of beginning to take them. Consequently, this is a more likely problem than substance use, organ damage, or adverse drug interactions.

1. An older adult is newly diagnosed with primary hypertension and has just been started on a beta-blocker. The nurse's health education should include which of the following? A) Increasing fluids to avoid extracellular volume depletion from the diuretic effect of the beta-blocker B) Maintaining a diet high in dairy to increase protein necessary to prevent organ damage C) Use of strategies to prevent falls stemming from postural hypotension D) Limiting exercise to avoid injury that can be caused by increased intracranial pressure

Ans: C Feedback: Elderly people have impaired cardiovascular reflexes and are more sensitive to postural hypotension. The nurse teaches patients to change positions slowly when moving from lying or sitting positions to a standing position, and counsels elderly patients to use supportive devices as necessary to prevent falls that could result from dizziness. Lifestyle changes, such as regular physical activity/exercise, and a diet rich in fruits, vegetables, and low-fat dairy products, is strongly recommended. Increasing fluids in elderly patients may be contraindicated due to cardiovascular disease. Increased intracranial pressure is not a risk and activity should not normally be limited.

19. The nurse is providing care for a patient with a diagnosis of hypertension. The nurse should consequently assess the patient for signs and symptoms of which other health problem? A) Migraines B) Atrial-septal defect C) Atherosclerosis D) Thrombocytopenia

Ans: C Feedback: Hypertension is both a sign and a risk factor for atherosclerotic heart disease. It is not associated with structural cardiac defects, low platelet levels, or migraines.

5. A group of student nurses are practicing taking blood pressure. A 56-year-old male student has a blood pressure reading of 146/96 mm Hg. Upon hearing the reading, he exclaims, "My pressure has never been this high. Do you think my doctor will prescribe medication to reduce it?" Which of the following responses by the nursing instructor would be best? A) "Yes. Hypertension is prevalent among men; it is fortunate we caught this during your routine examination." B) "We will need to reevaluate your blood pressure because your age places you at high risk for hypertension." C) "A single elevated blood pressure does not confirm hypertension. You will need to have your blood pressure reassessed several times before a diagnosis can be made." D) "You have no need to worry. Your pressure is probably elevated because you are being tested."

Ans: C Feedback: Hypertension is confirmed by two or more readings with systolic pressure of at least 140 mm Hg and diastolic pressure of at least 90 mm Hg. An age of 56 does not constitute a risk factor in and of itself. The nurse should not tell the student that there is no need to worry.

12. A patient in a hypertensive emergency is admitted to the ICU. The nurse anticipates that the patient will be treated with IV vasodilators, and that the primary goal of treatment is what? A) Lower the BP to reduce onset of neurologic symptoms, such as headache and vision changes. B) Decrease the BP to a normal level based on the patient's age. C) Decrease the mean arterial pressure between 20% and 25% in the first hour of treatment. D) Reduce the BP to 120/75 mm Hg as quickly as possible.

Ans: C Feedback: Initially, the treatment goal in hypertensive emergencies is to reduce the mean arterial pressure by 25% in the first hour of treatment, with further reduction over the next 24 hours. Lowering the BP too fast may cause hypotension in a patient whose body has adjusted to hypertension and could cause a stroke, MI, or visual changes. Neurologic symptoms should be addressed, but this is not the primary focus of treatment planning.

24. The nurse is collaborating with the dietitian and a patient with hypertension to plan dietary modifications. These modifications should include which of the following? A) Reduced intake of protein and carbohydrates B) Increased intake of calcium and vitamin D C) Reduced intake of fat and sodium D) Increased intake of potassium, vitamin B12 and vitamin D

Ans: C Feedback: Lifestyle modifications usually include restricting sodium and fat intake, increasing intake of fruits and vegetables, and implementing regular physical activity. There is no need to increase calcium, potassium, and vitamin intake. Calorie restriction may be required for some patients, but a specific reduction in protein and carbohydrates is not normally indicated.

34. A student nurse is taking care of an elderly patient with hypertension during a clinical experience. The instructor asks the student about the relationships between BP and age. What would be the best answer by the student? A) "Because of reduced smooth muscle tone in blood vessels, blood pressure tends to go down with age, not up." B) "Decreases in the strength of arteries and the presence of venous insufficiency cause hypertension in the elderly." C) "Structural and functional changes in the cardiovascular system that occur with age contribute to increases in blood pressure." D) "The neurologic system of older adults is less efficient at monitoring and regulating blood pressure."

Ans: C Feedback: Structural and functional changes in the heart and blood vessels contribute to increases in BP that occur with aging. Venous insufficiency does not cause hypertension, however. Increased BP is not primarily a result of neurologic changes.

25. The critical care nurse is caring for a patient just admitted in a hypertensive emergency. The nurse should anticipate the administration of what medication? A) Warfarin (Coumadin) B) Furosemide (Lasix) C) Sodium nitroprusside (Nitropress) D) Ramipril (Altace)

Ans: C Feedback: The medications of choice in hypertensive emergencies are those that have an immediate effect. IV vasodilators, including sodium nitroprusside (Nitropress), nicardipine hydrochloride (Cardene), clevidipine (Cleviprex), fenoldopam mesylate (Corlopam), enalaprilat, and nitroglycerin, have immediate actions that are short lived (minutes to 4 hours), and they are therefore used for initial treatment. Ramipril is administered orally and would not meet the patient's immediate need for BP management. Diuretics, such as Lasix, are not used as initial treatments and there is no indication for anticoagulants such as Coumadin.

37. A newly diagnosed patient with hypertension is prescribed Diuril, a thiazide diuretic. What patient education should the nurse provide to this patient? A) "Eat a banana every day because Diuril causes moderate hyperkalemia." B) "Take over-the-counter potassium pills because Diuril causes your kidneys to lose potassium." C) "Diuril can cause low blood pressure and dizziness, especially when you get up suddenly." D) "Diuril increases sodium levels in your blood, so cut down on your salt."

Ans: C Feedback: Thiazide diuretics can cause postural hypotension, which may be potentiated by alcohol, barbiturates, opioids, or hot weather. Diuril does not cause either moderate hyperkalemia or severe hypokalemia and it does not result in hypernatremia.

31. A community health nurse teaching a group of adults about preventing and treating hypertension. The nurse should encourage these participants to collaborate with their primary care providers and regularly monitor which of the following? A) Heart rate B) Sodium levels C) Potassium levels D) Blood lipid levels

Ans: D Feedback: Hypertension often accompanies other risk factors for atherosclerotic heart disease, such as dyslipidemia (abnormal blood fat levels), obesity, diabetes, metabolic syndrome, and a sedentary lifestyle. Individuals with hypertension need to monitor their sodium intake, but hypernatremia is not a risk factor for hypertension. In many patients, heart rate does not correlate closely with BP. Potassium levels do not normally relate to BP.

35. A 55-year-old patient comes to the clinic for a routine check-up. The patient's BP is 159/100 mm Hg and the physician diagnoses hypertension after referring to previous readings. The patient asks why it is important to treat hypertension. What would be the nurse's best response? A) "Hypertension can cause you to develop dangerous blood clots in your legs that can migrate to your lungs." B) "Hypertension puts you at increased risk of type 1 diabetes and cancer in your age group." C) "Hypertension is the leading cause of death in people your age." D) "Hypertension greatly increases your risk of stroke and heart disease."

Ans: D Feedback: Hypertension, particularly elevated systolic BP, increases the risk of death, stroke, and heart failure in people older than 50 years. Hypertension is not a direct precursor to pulmonary emboli, and it does not put older adults at increased risk of type 1 diabetes or cancer. It is not the leading cause of death in people 55 years of age.

4. The staff educator is teaching ED nurses about hypertensive crisis. The nurse educator should explain that hypertensive urgency differs from hypertensive emergency in what way? A) The BP is always higher in a hypertensive emergency. B) Vigilant hemodynamic monitoring is required during treatment of hypertensive emergencies. C) Hypertensive urgency is treated with rest and benzodiazepines to lower BP. D) Hypertensive emergencies are associated with evidence of target organ damage.

Ans: D Feedback: Hypertensive emergencies are acute, life-threatening BP elevations that require prompt treatment in an intensive care setting because of the serious target organ damage that may occur. Blood pressures are extremely elevated in both urgency and emergencies, but there is no evidence of target organ damage in hypertensive urgency. Extremely close hemodynamic monitoring of the patient's BP is required in both situations. The medications of choice in hypertensive emergencies are those with an immediate effect, such as IV vasodilators. Oral doses of fast-acting agents, such as beta-adrenergic blocking agents, angiotensin-converting enzyme inhibitors, or alpha-agonists, are recommended for the treatment of hypertensive urgencies.

26. A patient in hypertensive emergency is being cared for in the ICU. The patient has become hypovolemic secondary to natriuresis. What is the nurse's most appropriate action? A) Add sodium to the patient's IV fluid, as ordered. B) Administer a vasoconstrictor, as ordered. C) Promptly cease antihypertensive therapy. D) Administer normal saline IV, as ordered.

Ans: D Feedback: If there is volume depletion secondary to natriuresis caused by the elevated BP, then volume replacement with normal saline can prevent large, sudden drops in BP when antihypertensive medications are administered. Sodium administration, cessation of antihypertensive therapy, and administration of vasoconstrictors are not normally indicated.

38. A patient in hypertensive urgency is admitted to the hospital. The nurse should be aware of what goal of treatment for a patient in hypertensive urgency? A) Normalizing BP within 2 hours B) Obtaining a BP of less than 110/70 mm Hg within 36 hours C) Obtaining a BP of less than 120/80 mm Hg within 36 hours D) Normalizing BP within 24 to 48 hours

Ans: D Feedback: In cases of hypertensive urgency, oral agents can be administered with the goal of normalizing BP within 24 to 48 hours. For patients with this health problem, a BP of 120/80 mm Hg may be unrealistic.

30. The nurse is screening a number of adults for hypertension. What range of blood pressure is considered normal? A) Less than 140/90 mm Hg B) Less than 130/90 mm Hg C) Less than 129/89 mm Hg D) Less than 120/80 mm Hg

Ans: D Feedback: JNC 7 defines a blood pressure of less than 120/80 mm Hg as normal, 120 to 129/80 to 89 mm Hg as prehypertension, and 140/90 mm Hg or higher as hypertension.

28. A patient comes to the walk-in clinic complaining of frequent headaches. While assessing the patient's vital signs, the nurse notes the BP is 161/101 mm Hg. According to JNC 7, how would this patient's BP be defined if a similar reading were obtained at a subsequent office visit? A) High normal B) Normal C) Stage 1 hypertensive D) Stage 2 hypertensive

Ans: D Feedback: JNC 7 defines stage 2 hypertension as a reading 160/100 mm Hg.

40. A patient's recently elevated BP has prompted the primary care provider to prescribe furosemide (Lasix). The nurse should closely monitor which of the following? A) The client's oxygen saturation level B) The patient's red blood cells, hematocrit, and hemoglobin C) The patient's level of consciousness D) The patient's potassium level

Ans: D Feedback: Loop diuretics can cause potassium depletion. They do not normally affect level of consciousness, erythrocytes, or oxygen saturation.

33. The home health nurse is caring for a patient who has a comorbidity of hypertension. What assessment question most directly addresses the possibility of worsening hypertension? A) "Are you eating less salt in your diet?" B) "How is your energy level these days?" C) "Do you ever get chest pain when you exercise?" D) "Do you ever see spots in front of your eyes?"

Ans: D Feedback: To identify complications or worsening hypertension, the patient is questioned about blurred vision, spots in front of the eyes, and diminished visual acuity. The heart, nervous system, and kidneys are also carefully assessed, but angina pain and decreased energy are not normally suggestive of worsening hypertension. Sodium limitation is a beneficial lifestyle modification, but nonadherence to this is not necessarily a sign of worsening symptoms.

21. A patient with newly diagnosed hypertension has come to the clinic for a follow-up visit. The patient asks the nurse why she has to come in so often. What would be the nurse's best response? A) "We do this so you don't suffer a stroke." B) "We do this to determine how your blood pressure changes throughout the day." C) "We do this to see how often you should change your medication dose." D) "We do this to make sure your health is stable. We'll then monitor it at routinely scheduled intervals."

Ans: D Feedback: When hypertension is initially detected, nursing assessment involves carefully monitoring the BP at frequent intervals and then at routinely scheduled intervals. The reference to stroke is frightening and does not capture the overall rationale for the monitoring regimen. Changes throughout the day are not a clinical priority for most patients. The patient must not change his or her medication doses unilaterally.

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. Ask 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 a history of hypertension. The patient's medication history includes hydrochlorothiazide daily for the past 10 years. Which parameter would indicate the optimal intended effect of this drug therapy? BP 128/78 mm Hg Weight loss of 2 lb Absence of ankle edema Output of 600 mL per 8 hours

BP 128/78 mm Hg Rationale: Hydrochlorothiazide may be used alone as monotherapy to manage hypertension or in combination with other medications if not effective alone. After the first few weeks of therapy, the diuretic effect diminishes, but the antihypertensive effect remains. Because the patient has been taking this medication for 10 years, the most direct measurement of its intended effect would be the blood pressure.

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 admits a 73-yr-old male patient with dementia for treatment of uncontrolled hypertension. The nurse will closely monitor for hypokalemia if the patient receives which medication? Clonidine (Catapres) Bumetanide (Bumex) Amiloride (Midamor) Spironolactone (Aldactone)

Bumetanide (Bumex) Rationale: Bumetanide is a loop diuretic. Hypokalemia is a common adverse effect of this medication. Amiloride is a potassium-sparing diuretic. Spironolactone is an aldosterone-receptor blocker. Hyperkalemia is an adverse effect of both amiloride and spironolactone. Clonidine is a central-acting α-adrenergic antagonist and does not cause electrolyte abnormalities.

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?Correct Answer 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.

When teaching how lisinopril (Zestril) will help lower the patient's blood pressure, which mechanism of action should the nurse explain? Blocks β-adrenergic effects. Relaxes arterial and venous smooth muscle. Inhibits conversion of angiotensin I to angiotensin II. Reduces sympathetic outflow from central nervous system.

Inhibits conversion of angiotensin I to angiotensin II. Rationale: Lisinopril is an angiotensin-converting enzyme inhibitor that inhibits the conversion of angiotensin I to angiotensin II, which reduces angiotensin II-mediated vasoconstriction and sodium and water retention. β-Blockers result in vasodilation and decreased heart rate. Direct vasodilators relax arterial and venous smooth muscle. Central-acting α-adrenergic antagonists reduce sympathetic outflow from the central nervous system to produce vasodilation and decreased systemic vascular resistance and blood pressure.

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 uses a mixed β-adrenergic blocking drug for treatment of migraine headaches. What effect may this drug have on BP and why?

The drug will lower BP because of decreased stroke volume and decreased HR, both of which decrease CO.

A patient is given an α1-adrenergic agonist and experiences a reflex bradycardia. What normal mechanism of BP control is stimulated in this situation?

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.

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

a. Decrease the mean arterial pressure (MAP) to 129 mm Hg 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.

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

a. No symptoms 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.

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.

a. The drug should never be stopped abruptly. 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.

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

b. Atherosclerotic changes in vessels that supply the organs 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.

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.

b. Change position slowly and avoid prolonged standing. 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.

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

b. Heart 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.

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.

b. Obtain orthostatic BP readings for older patients. 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.

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."

c. "The drugs you are taking cause sexual dysfunction in many patients. Are you experiencing any problems in this area?" 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.

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

c. A sudden rise in BP accompanied by neurologic impairment 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.

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)

c. Decrease CO by decreasing rate and strength of the heart and renin secretion by the kidneys 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).

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

c. Has a specific cause, such as renal disease, that often can be treated by medicine or surgery 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.

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)

d. Fenoldopam (Corlopam) and sodium nitroprusside (Nitropress) 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.

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

d. Hydrochlorothiazide 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.

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

d. Instructing the patient to follow up with a health care provider within 24 hours after outpatient treatment 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.

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.

d. Take readings at least 2 times at least 1 minute apart. 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.

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

d. Vasodilation, prevents the action of angiotensin II, and promotes increased salt and water excretion 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.