326 PrepU - ch.27: assessment and management of patients with hypertension

A 77-year-old client presents to the local community center for a blood pressure (BP) screening; BP is recorded as 180/90 mm Hg. The client has a history of hypertension but currently is not taking the prescribed medications. Which question is most appropriate for the nurse to ask the client first?

"Can you tell me the reasons you aren't taking your medications?" Rationale: It is important for the nurse to first ascertain why the client is not taking prescribed medications. Adherence to the therapeutic program may be more difficult for older adults. The medication regimen can be difficult to remember, and the expense can be a challenge. Monotherapy (treatment with a single agent), if appropriate, may simplify the medication regimen and make it less expensive. The other questions are appropriate, but the priority is to determine why the medication regimen is not being followed.

A nurse is caring for a client who has hypertension and diabetes mellitus. The client's blood pressure this morning was 150/92 mm Hg. When the client asks the nurse what his or her blood pressure should be, what is the nurse's most appropriate response?

"Clients with diabetes should have a lower blood pressure goal. You should strive for 120/80 mm Hg." Rationale: An individual with diabetes mellitus should strive for blood pressure of 120/80 mm Hg or less. An individual without diabetes should strive for blood pressure of 140/90 mm Hg or less.

Which client statement indicates a good understanding of the nutritional modifications needed to manage hypertension?

"Limiting my salt intake to 2 grams per day will improve my blood pressure." Rationale: To lower blood pressure, a client should limit daily salt intake to 2 g or less. Alcohol intake is associated with a higher incidence of hypertension, poor compliance with treatment, and refractory hypertension. Moderate caffeine and fat intake don't significantly affect blood pressure.

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." Rationale: 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.

Hypertension is diagnosed when the client demonstrates a systolic blood pressure greater than ______ mm Hg or a diastolic blood pressure greater than _____ mm Hg over a sustained period.

130, 80 Rationale: The latest guidelines (November 2017) released by the American College of Cardiology and the American Heart Association are: Normal blood pressure: Systolic less than 120 mm Hg and diastolic less than 80 mm Hg. Elevated blood pressure: Systolic between 120 and 129 mm Hg and diastolic less than 80 mm Hg. Stage 1 hypertension: Systolic between 130 and 139 mm Hg or diastolic between 80 and 89 mm Hg. Stage 2 hypertension: Systolic of 140 or greater mm Hg or diastolic of 90 or greater mm Hg.

A nurse is teaching a client who is newly diagnosed with hypertension and diabetes mellitus. What will the nurse specify about this client's target blood pressure?

130/80 or lower Rationale: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) specifies a lower goal pressure of 130/80 for people with diabetes mellitus.

The nurse is teaching a client diagnosed with hypertension about the DASH diet. How many servings of meat, fish, and poultry should the client consume per day?

2 or fewer Rationale: Two or fewer servings of lean meat, fish, and poultry are recommended in the DASH diet. The diet also recommends two or three servings of low-fat or fat-free dairy foods, four or five servings of fruits and vegetables, and seven or eight servings of grains and grain products.

A patient is being treated for hypertensive emergency. When treating this patient, the priority goal is to lower the mean blood pressure (BP) by up to which percentage in the first hour?

25% Rationale: The therapeutic goals are reduction of the mean BP by up 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 2 to 6 hours, and then a more gradual reduction in pressure to the target goal over a period of days.

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

4 or 5 Rationale: 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 caring for an elderly client with a diagnosis of hypertension, who is taking several antihypertensive medications. Which safety precaution is the nurse most likely to reinforce?

Changing positions slowly related to possible hypotension Rationale: The elderly have impaired cardiovascular reflexes and thus are more sensitive to the extracellular volume depletion caused by diuretics and to the sympathetic inhibition caused by adrenergic antagonists. The nurse teaches clients to change positions slowly when moving from a lying or sitting position to a standing position. This will help prevent falls. Eating extra potassium is not a good idea if taking a potassium-sparing diuretic. The other choices are good teaching points, but not necessarily safety precautions.

A client has severe coronary artery disease (CAD) and hypertension. Which medication order should the nurse consult with the health care provider about that is contraindicated for a client with severe CAD?

Clonidine Rationale: Clonidine (Catapres) is contraindicated for clients with severe coronary artery disease.

The nurse is teaching a client who is experiencing dizziness to rise slowly from a sitting or lying position. What is the rationale for the teaching?

Gradual changes in position provide time for the heart to increase rate of contraction to resupply oxygen to the brain Rationale: It is important for the nurse to encourage the patient to rise slowly from a sitting or lying position because gradual changes in position provide time for the heart to increase its rate of contraction to resupply oxygen to the brain. Blood pressure and heart rate do not affect this process.

A client is admitted to the intensive care unit (ICU) with a diagnosis of hypertension emergency/crisis. The client's blood pressure (BP) is 200/130 mm Hg. The nurse is preparing to administer IV nitroprusside. Upon assessment, which finding requires immediate intervention by the nurse?

Numbness and weakness in the left arm Rationale: 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. The finding of numbness and weakness in left arm may indicate the client is experiencing neurological symptoms associated with an ischemic stroke because of the severely elevated BP; immediate intervention is required. Urine output of 40 mL/h is within normal limits. The other findings are likely caused by the hypertension and require intervention, but they do not require action as urgently as the neurologic changes.

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 Rationale: 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.

Nurses should implement measures to relieve emotional stress for clients with hypertension because the reduction of stress

decreases the production of neurotransmitters that constrict peripheral arterioles Rationale: Reduced stress decreases the production of neurotransmitters that constrict peripheral arterioles. Reduced stress may assist in reducing blood volume and resistance to the heart.

A client who is newly diagnosed with hypertension is going to be starting antihypertensive medicine. What is one of the main things the client and the client's spouse should watch for?

dizziness Rationale: A common adverse effect of all antihypertensive drugs is postural hypotension, which can lead to falls. The client and the client's spouse should be alerted to this possibility and provided with some tips for managing dizziness.

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

hypertensive emergency Rationale: 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.

It is appropriate for the nurse to recommend smoking cessation for clients with hypertension because nicotine

increases the heart rate, constricts arterioles, and reduces the heart's ability to eject blood Rationale: The nurse recommends smoking cessation for clients with hypertension because nicotine raises the heart rate, constricts arterioles, and reduces the heart's ability to eject blood. Reduced oral fluids decrease the circulating blood volume.

The nurse is caring for an older adult client who has come to the clinic for a yearly physical. When assessing the client, the nurse notes the blood pressure (BP) is 140/93. The nurse knows that in older clients what happens that may elevate the systolic BP?

loss of arterial elasticity Rationale: In older clients, systolic BP may be elevated because of loss of arterial elasticity (arteriosclerosis). Systolic BP would not become elevated by a decrease in blood volume, an increase in calcium intake, or a decrease in cardiac output.

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 Rationale: 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.

Which term is refers to hypertension in which blood pressure that is controlled with therapy becomes uncontrolled (abnormally high) when the therapy is discontinued?

rebound Rationale: Rebound hypertension may precipitate a hypertensive crisis. Essential or primary hypertension denotes high blood pressure from an unidentified source. Secondary hypertension denotes high blood pressure from an identified cause, such as renal disease.

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 Rationale: 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.

Which of the following is the nurse most correct to recognize as a direct effect of client hypertension?

renal dysfunction resulting from atherosclerosis Rationale: The nurse is most correct to realize high blood pressure damages the arterial vascular system and accelerates atherosclerosis. The effect of the atherosclerosis impairs circulation to the kidney, resulting in renal failure. Neither anemia, hyperglycemia, nor emphysema occurs as a direct effect of hypertension.

A client, newly admitted to the nursing unit, has a primary diagnosis of renal failure. When assessing the client, the nurse notes a blood pressure (BP) of 180/100. The nurse knows that this is what kind of hypertension?

secondary Rationale: Secondary hypertension is elevated BP that results from or is secondary to some other disorder. This type of hypertension is not primary, essential, or malignant.

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

A 66-year-old client presents to the emergency department reporting severe headache and mild nausea for the past 6 hours. Upon assessment, the client's BP is 210/120 mm Hg. The client has a history of hypertension and takes 1.0 mg clonidine twice daily. Which question is most important for the nurse to ask the client next?

"Have you taken your prescribed clonidine today?" Rationale: The nurse must ask whether the client has taken his prescribed clonidine. Clients need to be informed that rebound hypertension can occur if antihypertensive medications are suddenly stopped. Specifically, a side effect of clonidine is rebound or withdrawal hypertension. Although the other questions may be asked, it is most important to inquire whether the client has taken the prescribed hypertension medication given the client's severely elevated BP.

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." Rationale: 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 educating a client about monitoring blood pressure readings at home. What will the nurse be sure to emphasize?

"Sit quietly for 5 minutes prior to taking blood pressure." Rationale: Instructions for the client regarding measuring the blood pressure at home include the following: (1) Avoid smoking cigarettes or drinking caffeine for 30 minutes before measuring blood pressure. (2) Sit quietly for 5 minutes before the measurement. (3) Have the forearm supported at heart level, with both feet on the ground during the measurement of the blood pressure.

A client is newly diagnosed with hypertension. For which classifications of first-line antihypertensive agents will the nurse prepare teaching for this client? Select all that apply.

- Thiazide diuretic - Calcium channel blocker - Angiotensin-converting enzyme inhibitor Rationale: Research findings have demonstrated that appropriately prescribing antihypertensive pharmacologic agents lowers BP, and reduces the risk of cardiovascular disease (CVD), cerebrovascular disease, and death. The medications that have been shown to prevent CVD are recommended as first-line agents for most clients. This first-line group includes thiazide or thiazide-type diuretics, calcium channel blockers (CCBs), and angiotensin-converting enzyme (ACE) inhibitors. Beta blockers and loop diuretics are considered second-line antihypertensive agents.

A nurse is providing education about hypertension to a community group. What are possible consequences of untreated hypertension? Select all that apply.

- coronary artery disease - myocardial infarction - stroke

A patient with hypertension is waking up several times a night to urinate. The nurse knows that what laboratory studies may indicate pathologic changes in the kidneys due to the hypertension? (Select all that apply.)

- creatinine - blood urea nitrogen (BUN)

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 rate - heart rhythm - character of apical and peripheral pulses

A client has come to the clinic for a follow-up assessment that will include a BP reading. To ensure an accurate reading, the nurse confirms that the client has performed which action(s)? Select all that apply.

- positioned arm at heart level - tried to rest quietly for 5 minutes before the reading is taken

The nurse is caring for a client who has just received a diagnosis of hypertension. What lifestyle change(s) should the nurse recommend to the client to decrease the consequences of hypertension? Select all that apply.

- restrict salt/sodium - manage stress effectively - adhere to an exercise plan - reduce caffeine intake Rationale: Obesity, inactivity, smoking, excessive alcohol intake, and ineffective stress management are risk factors for hypertension. The nurse should help the client reduce or eliminate the use of caffeine and tobacco, restrict salt/sodium intake, manage stress effectively, and adhere to an exercise plan as part of the client's treatment regimen.

The nurse is instructing a client with hypertension. What will the nurse teach the client to do before measuring the blood pressure at home? Select all that apply.

- sit quietly for 5 minutes - do not smoke for 30 minutes - avoid talking during measurement - place the forearm at heart level on a firm surface Rationale: The client with hypertension will be instructed to measure the blood pressure at home. Before measuring the blood pressure, the client should be instructed to sit quietly for 5 minutes, avoid smoking 30 minutes before the measurement, avoid talking during the measurement, and to place the forearm at heart level on a firm surface. These instructions help ensure the client's blood pressure measurement is accurate. There is no reason for the client to drink a glass of water before measuring the blood pressure.

A nurse providing education about hypertension to a community group is discussing the high risk for cardiovascular complications. What are risk factors for cardiovascular problems in clients with hypertension? Select all that apply.

- smoking - diabetes mellitus - physical inactivity

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's arm should be positioned at the level of the heart - the client should sit quietly while BP is being measured

A nurse is educating about lifestyle modifications for a group of clients with newly diagnosed hypertension. While discussing dietary changes, which point would the nurse emphasize?

It takes 2 to 3 months for the taste buds to adapt to decreased salt intake Rationale: It takes 2 to 3 months for the taste buds to adapt to changes in salt intake. Knowing this may help the client adjust to reduced salt intake. The client should be advised to limit alcohol intake.

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 Rationale: 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.

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 Rationale: 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 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 Rationale: 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 who is prescribed medication for the treatment of hypertension. The nurse recognizes that which medication conserves potassium?

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

The nurse is caring for a client with essential hypertension. The nurse reviews lab work and assesses kidney function. Which action of the kidney would the nurse evaluate as the body's attempt to regulate high blood pressure?

The kidney excretes sodium and water Rationale: Hypernatremia (elevated serum sodium level) increases blood volume, which raises blood pressure. The kidney's response to the elevation in blood pressure is to excrete sodium and excess water. Any retention of sodium and water would increase blood volume and, thus, blood pressure. Sodium and water move together.

A community health nurse is screening for hypertension. Which client would the nurse focus on most intensively?

a middle-aged black man Rationale: Statistically, Black people have the highest prevalence of hypertension. The other choices all have a lower incidence of hypertension, so the nurse should pay the greatest attention to the middle-aged Black man.

A client with newly diagnosed hypertension asks what to do to decrease the risk for related cardiovascular problems. Which risk factor is not modifiable by the client?

age

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 Rationale: 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.

A client is being seen at the clinic for a routine physical when the nurse notes the client's blood pressure is 150/97. The client is considered to be a healthy, well-nourished young adult. What type of hypertension does this client have?

essential (primary) Rationale: Essential or primary hypertension, about 95% of cases, is sustained elevated BP with no known cause. This client does not have secondary, pathologic, or malignant hypertension.

The nurse is creating a community teaching demonstration focusing on the cause of blood pressure. When completing the visual aid, which body structures represent the mechanism of blood pressure?

heart blood vessels Rationale: Blood pressure is the force produced by the volume of the blood in arterial walls. It is represented by the formula: BP = CO (cardiac output) * PR (peripheral resistance). To highlight the mechanism of cardiac output, a heart would be on the visual aid and blood vessels.

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 Rationale: 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.