Chapter 31: Patients with Hypertension

The nurse is caring for a client who has had 25 mg of oral hydrochlorothiazide added to the medication regimen for the treatment of hypertension. Which instruction should the nurse give the client?

"Increase the amount of fruits and vegetables you eat." Thiazide diuretics cause loss of sodium, potassium, and magnesium, so the client should be encouraged to eat fruits and vegetables that are high in potassium. Diuretics cause increased urination; the client should not take the medication before going to bed. Thiazide diuretics do not cause dry mouth or nasal congestion; both side effects are associated with alpha2-agonists. Postural hypotension may be potentiated by alcohol.

A nurse is teaching a client with newly diagnosed hypertension who asks if there is any harm in stopping antihypertensive medication. What is the nurse's best response?

"Rebound hypertension can occur." Clients need to be informed that rebound hypertension can occur if they stop antihypertensive medications suddenly. This can be extremely dangerous and have serious consequences. Hypotension would not be a problem with discontinuation of antihypertensive medications.

The nurse is performing an assessment on a patient to determine the effects of hypertension on the heart and blood vessels. What specific assessment data will assist in determining this complication? (Select all that apply.)

-Heart rhythm -Character of apical and peripheral pulses -Heart rate During the physical examination, the nurse must also pay specific attention to the rate, rhythm, and character of the apical and peripheral pulses to detect the effects of hypertension on the heart and blood vessels.

According to the DASH diet, how many servings of vegetables should a person consume each day?

4 or 5 Four or five servings of vegetables are recommended in the DASH diet. The diet recommends two or fewer servings of lean meat, fish, and poultry; two or three servings of low-fat or fat-free dairy foods; and seven or eight servings of grains and grain products.

The nurse is assessing the blood pressure for a patient who has hypertension and the nurse does not hear an auscultatory gap. What outcome may be documented in this circumstance?

A high diastolic or low systolic reading An auscultatory gap is when the Korotkoff sounds disappear for a brief period as the cuff is being deflated. Failure to notice an auscultatory gap can result in erroneously high diastolic or low systolic pressure readings (Ogedegbe & Pickering, 2010).

A patient with long-standing hypertension is admitted to the hospital with hypertensive urgency. The physician orders a chest x-ray, which reveals an enlarged heart. What diagnostic test does the nurse anticipate preparing the patient for to determine left ventricular enlargement?

Echocardiography Left ventricular hypertrophy can be assessed by echocardiography, but not by any of the other measures listed.

The nurse is instructing a student on the proper technique for measuring blood pressure (BP). Which student action indicates a need for further teaching?

Positions the arm at waist level Positioning the arm above the heart level will give a falsely low reading. Placing the arm below the heart will falsely elevate the reading. All other options are correct steps in achieving an accurate blood pressure.

When measuring the blood pressure in each arm of a healthy adult client, the nurse recognizes that which statement is true?

Pressures should not differ more than 5 mm Hg between arms. Normally, in the absence of any disease of the vasculature, arm pressures differ by no more than 5 mm Hg. The pressures in each arm do not have to be equal to be considered normal. Pressures that vary more than 10 mm Hg between arms are an abnormal finding. The left arm pressure is not anticipated to be higher than the right as a normal anatomic variant.

A patient is flying overseas for 1 week for business and packed antihypertensive medications in a suitcase. After arriving at the intended destination, the patient found that the luggage had been stolen. If the patient cannot take the medication, what condition becomes a concern?

Rebound hypertension Patients need to be informed that rebound hypertension can occur if antihypertensive medications are suddenly stopped. Thus, patients should be advised to have an adequate supply of medication, particularly when traveling and in case of emergencies such as natural disasters. If traveling by airplane, patients should pack the medication in their carry-on luggage.

The nurse is instructing a client who is newly prescribed an antihypertensive medication. Which nursing instruction is emphasized to maintain client safety?

Sit on the edge of the chair and rise slowly. The nursing instruction emphasized to maintain client safety is to sit on the edge of the chair before rising slowly. By doing so, the client reduces the possibility of falls related to postural hypotension. Using a pillbox to store medications and taking the medication at the same time daily is good medication management instruction. There is no reason when taking antihypertensive medications to restrict driving.

The nurse is administering medications on a medical-surgical unit. A client is ordered to receive 40 mg oral nadolol for the treatment of hypertension. Before administering the medication, the nurse should

check the client's heart rate. Nadolol is a beta-blocker. A desired effect of this medication is to reduce the pulse rate in clients with tachycardia and elevated blood pressure (BP). The nurse should check the client's heart rate (HR) before administering nadolol to ensure that the pulse is not less than 60 beats per minute. The other interventions are not indicated before administering a beta-blocker medication.

The nurse is caring for a client with a blood pressure of 210/100 mm Hg in the emergency room. What is the most appropriate route of administration for antihypertensive agents?

continuous IV infusion The medications of choice in hypertensive emergencies are best managed through the continuous IV infusion of a short-acting titratable antihypertensive agent. The nurse avoids the sublingual and IM routes as their absorption and dynamics are unpredictable. The oral route would not have as quick an onset as a continuous IV infusion.

The nurse is teaching a client about hypertension and the effects on the left ventricle. What diagnostic test will the nurse describe?

echocardiography Echocardiography will reveal an enlarged left ventricle. Fluorescein angiography reveals leaking retinal blood vessels, and a PET scan is used to reveal abnormalities in blood pressure. A CT scan reveals structural abnormalities.

Papilledema is a fairly common symptom of elevated blood pressure. The best way to detect this condition is through:

ophthalmic examination. Papilledema is an edema of the optic nerves, and thus needs an ophthalmic examination for detection.

The nurse is teaching a client about chronic untreated hypertension. What complication will the nurse explain to the client?

stroke A stroke occurs if vessels in the brain rupture and bleed. If an aneurysm has developed in the aorta from chronic hypertension, it may burst and cause hemorrhage and shock. Peripheral edema, right-sided heart failure, and pulmonary insufficiency are not usually consequences of untreated chronic hypertension.

Which statements are true when the nurse is measuring blood pressure (BP)? Select all that apply.

-Using a BP cuff that is too small will give a higher BP measurement. -The client should sit quietly while BP is being measured. -The client's arm should be positioned at the level of the heart. Using a BP cuff that is too small will give a higher BP measurement. The client should sit quietly while BP is being measured. The client's arm should be positioned at the level of the heart.

What risk factors would cause the nurse to become concerned that the client may have atherosclerotic heart disease? Select all that apply.

-diabetes -family history of early cardiovascular events -obesity -hypertension Risk factors for atherosclerotic heart disease include hypertension, dyslipidemia (including high total, low-density lipoprotein [LDL], and triglyceride levels as well as low high-density lipoprotein [HDL] levels), obesity, diabetes, a family history of early cardiovascular events, metabolic syndrome, a sedentary lifestyle, and obstructive sleep apnea.

Which describes a situation in which blood pressure is severely elevated and there is evidence of actual or probable target organ damage?

Hypertensive emergency A hypertensive emergency is a situation in which blood pressure is severely elevated and there is evidence of actual or probable target organ damage. Hypertensive urgency is a situation in which blood pressure is severely elevated but there is no evidence of actual or probable target organ damage. Secondary hypertension is high blood pressure from an identified cause, such as renal disease. Primary hypertension denotes high blood pressure from an unidentified source.

Which term describes high blood pressure from an identified cause, such as renal disease?

Secondary hypertension Secondary hypertension is high blood pressure from an identified cause, such as renal disease. Primary hypertension denotes high blood pressure form an unidentified source. Rebound hypertension is pressure that is controlled with therapy and becomes uncontrolled (abnormally high) when that therapy is discontinued. A hypertensive emergency is a situation in which blood pressure is severely elevated and there is evidence of actual or probable target organ damage.

Which diuretic medication conserves potassium?

Spironolactone Spironolactone is known as a potassium-sparing diuretic. Furosemide causes loss of potassium from the body. Chlorothiazide and chlorthalidone cause mild hypokalemia.

As recommended follow-up for a client initially diagnosed with prehypertension, the client should get his or her blood pressure rechecked within which time frame?

Recheck in 1 year A client with an initial blood pressure (BP) in the prehypertension range should have his or her BP rechecked in 1 year. A normal BP should be rechecked in 2 years. Stage 1 hypertension should be confirmed and followed up within 2 months. Stage 2 hypertension should be evaluated or referred to a source of care within 1 month.

An older adult client has newly diagnosed stage 2 hypertension. The health care provider has prescribed Chlorothiazide and Benazepril. What will the nurse monitor this client for?

Postural hypotension and resulting injury Antihypertensive medication can cause hypotension, especially postural hypotension that may result in injury. Rebound hypertension occurs when antihypertensive medication is stopped abruptly. Sexual dysfunction may occur, especially with beta blockers, but other medications are available should this problem ensue. This is not immediately a priority concern. Antihypertensive medications do not usually cause postural hypertension.

A nurse educator is providing information about hypertension to a small group of clients. A participant asks "What can I do to decrease my blood pressure and thus my risk for heart problems?" The nurse describes modifiable and nonmodifiable risk factors. Which of the following risk factors can the client modify?

Dyslipidemia Modifiable risk factors for cardiovascular problems in clients with hypertension include smoking, dyslipidemia, diabetes mellitus, impaired renal function, obesity, and physical inactivity.

A client is taking 50 mg of oral spironolactone twice a day to assist with blood pressure control. While the nurse is performing the morning assessment, the client reports nausea, general muscle cramps, and weakness. The ECG strip shows a peaked, narrow T-wave, which is a change. What electrolyte imbalance does the nurse suspect?

Hyperkalemia Potassium-sparing diuretics, such as spironolactone, can cause hyperkalemia, especially if given with an ACE inhibitor. Signs of hyperkalemia are nausea, diarrhea, abdominal cramps, and peaked narrow T-waves.

A client is taking amiloride and lisinopril for the treatment of hypertension. What laboratory studies should the nurse monitor while the client is taking these two medications together?

Potassium level Amiloride (Midamor) is a potassium-sparing diuretic, meaning that it causes potassium retention. The nurse should monitor for hyperkalemia (elevated potassium level) if given with an ACE inhibitor, such as lisinopril (Zestril) or angiotensin receptor blocker.

A client is brought to the emergency department with reports of a bad headache and an increase in blood pressure. The blood pressure reading obtained by the nurse is 260/180 mm Hg. What is the therapeutic goal for reduction of the mean blood pressure?

Reduce the blood pressure by 20% to 25% within the first hour of treatment. A hypertensive emergency is a situation in which blood pressures are extremely elevated and must be lowered immediately (not necessarily to less than 140/90 mm Hg) to halt or prevent damage to the target organs (Chobanian et al., 2003; Rodriguez et al., 2010). Hypertensive emergencies are acute, life-threatening blood pressure elevations that require prompt treatment in an intensive care setting because of the serious target organ damage that may occur. The therapeutic goals are reduction of the mean blood pressure by 20% to 25% within the first hour of treatment, a further reduction to a goal pressure of about 160/100 mm Hg over a period of up to 6 hours, and then a more gradual reduction in pressure over a period of days.

The nurse is caring for a client newly diagnosed with secondary hypertension. Which condition contributes to the development of secondary hypertension?

Renal disease Secondary hypertension occurs when a cause for the high blood pressure can be identified. These causes include renal parenchymal disease, narrowing of the renal arteries, hyperaldosteronism (mineralocorticoid hypertension), pheochromocytoma, certain medications (e.g., prednisone, epoetin alfa), and coarctation of the aorta. High blood pressure can also occur with pregnancy; women who experience high blood pressure during pregnancy are at increased risk of ischemic heart disease, heart attack, stroke, kidney disease, diabetes, and death from heart attack. Calcium deficiency or acid-based imbalance does not contribute to hypertension.

Which finding indicates that hypertension is progressing to target organ damage?

Retinal blood vessel damage Symptoms suggesting that hypertension is progressing to the extent that target organ damage is occurring must be detected early so that appropriate treatment can be initiated. All body systems must be assessed to detect any evidence of vascular damage. An eye examination with an ophthalmoscope is important because retinal blood vessel damage indicates similar damage elsewhere in the vascular system. The client 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. A BUN concentration of 12 mg/dL and urine output of 60 mL over 2 hours are normal findings. The presence of pneumonia does not indicate target organ damage.

The nurse is seeing a client for the first time and has just checked the client's blood pressure. The nurse would consider the client prehypertensive if:

systolic BP is between 120 and 139 mm Hg. Once the systolic BP goes above 120 mm Hg, the patient is considered prehypertensive, according to the National Heart, Lung, and Blood Institute's (2015) definition.