Venous Thromboembolism and Hypertensive Emergency

Which rationale will the nurse provide when a patient with a venous thromboembolism (VTE) asks why heparin has been prescribed? "This medication works to dissolve the clot in your leg." "Heparin prevents formation of a new clot at the site." "The medication will prevent the clot from moving." "Heparin forms a protective layer around the thromboembolism."

"Heparin prevents formation of a new clot at the site." In the acute phase, VTE can be treated with intravenous heparin or subcutaneous low-molecular-weight heparin, which can prevent new thrombi from forming.

Which statement would the nurse expect a patient with a deep vein thromboembolism to make? "The pain gets worse when I walk around the room." "My leg feels like it is constantly burning." "My calf hurts when I point my toes upward." "I'm so glad this swelling in my legs went down."

"The pain gets worse when I walk around the room." Pain from deep vein thrombosis worsens with ambulation and activity.

Which patient statement indicates understanding of the methods used to prevent a venous thromboembolism? "I will keep my legs crossed when I am in bed." "I should only wear the compression stockings for 2 hours." "The aspirin will prevent me from getting a blood clot." "The pneumatic compression boots will squeeze my legs."

"The pneumatic compression boots will squeeze my legs." Pneumatic compression boots apply rhythmic pressure to the patient's legs to encourage blood flow and prevent venous thrombosis.

Match the hypertensive emergency trigger with the corresponding cause. 1. Aortic dissection 2. Scleroderma 3. Malignant hypertension 4. Eclampsia a. Catecholamine excess b. Chest pain c. Kidney failure d. Papilledema

1. a 2. b 3. c 4. d

Which blood pressure value would meet the criteria for hypertensive emergency? Select all that apply. One, some, or all responses may be correct. 150/95 mm Hg 200/110 mm Hg 190/130 mm Hg 225/125 mm Hg 182/121 mm Hg

190/130 mm Hg A patient with a hypertensive emergency would have a blood pressure greater than 180/120 mm Hg. The systolic and diastolic values of 190/130 mm Hg are greater than the threshold. 225/125 mm Hg A blood pressure of 225/125 mm Hg is higher than 180/120 mm Hg and therefore meets the criteria for a hypertensive emergency. 182/121 mm Hg A patient with a hypertensive emergency would have a blood pressure greater than 180/120 mm Hg. A blood pressure of 182/121 mm Hg is greater than the threshold.

The nurse would plan to implement pharmacologic and mechanical deep vein thrombosis (DVT) prophylaxis for which patient? 26-year-old anxious patient who paces the halls 48-year-old patient with chronic obstructive pulmonary disease (COPD) who has shortness of breath 67-year-old hip fracture patient who is on bed rest 82-year-old patient with Alzheimer who moves around frequently

67-year-old hip fracture patient who is on bed rest Immobility, age, and long bone fractures all increase the risk of DVT; therefore, this patient would require multilevel prevention strategies.

The nurse would monitor for which potential complication when caring for a patient with hypertensive emergency? Select all that apply. One, some, or all responses may be correct. Acute myocardial infarction Stroke Infection Pulmonary embolism Renal failure

Acute myocardial infarction An acute myocardial infarction can occur if the myocardium experiences necrosis from an oxygen supply and demand mismatch. Stroke Stroke can occur if the brain experiences ischemia due to the hypertensive crisis. Renal failure Renal failure can occur if the hypertension causes end-organ damage to the kidneys.

Which intervention would the nurse include in the plan of care for a patient with hypertensive emergency? Reduce the blood pressure (BP) by at least 35% every hour. Monitor BP every hour. Administer nifedipine and monitor for a response. Assess for headache, chest pain, and decreased urinary output.

Assess for headache, chest pain, and decreased urinary output. Headache, chest pain, and decreased urinary output are all signs of end-organ damage. It is appropriate to continually assess for these manifestations.

Which test would be used to assess for the presence of a deep vein thrombosis (DVT)? Select all that apply. One, some, or all responses may be correct. Radiographs Ventilation-perfusion scan D-dimer Ultrasonography Serum electrolytes

D-dimer The D-dimer test measures the presence of cross-linked fibrin derivatives in the serum. It is a sensitive marker of thrombosis but it lacks specificity. Ultrasonography When DVT is suspected, noninvasive venous ultrasonography is typically performed to evaluate vein patency.

Hypertensive emergency in response to a food-medication interaction is most likely to occur in a patient with which diagnosis? Depression Asthma Cancer Infection

Depression Monoamine oxidase inhibitors, a class of antidepressants, cause hypertensive crisis when mixed with tyramine.

Which medication would be used to prevent a venous thromboembolism (VT) in a critically ill patient? Aspirin Fondaparinux Vitamin K High-dose heparin

Fondaparinux Pharmacologic thromboprophylaxis with low-molecular-weight heparin (subcutaneous administration), fondaparinux, or rivaroxaban is recommended.

Which medication would the nurse use to treat a hypertensive emergency related to eclampsia? Sodium nitroprusside Nitroglycerin Hydralazine Nicardipine

Hydralazine Hydralazine is the intravenous agent of choice in eclampsia because it does not cross the placental barrier.

Which finding would the nurse immediately report to the health care provider when caring for a patient with a deep vein thrombosis (DVT) in the left leg? Unilateral leg swelling Redness of the left leg Elevated D-dimer Increased respiratory rate

Increased respiratory rate Breathlessness, chest pain, and increased respiratory rate are all signs of pulmonary embolism and would need to be reported immediately.

The nurse is assessing a patient and notes that the right lower extremity is red, swollen, and painful. Based on the assessment findings, which action would the nurse take? Monitor for other signs of sepsis. Ask the patient if there is a history of heart failure. Notify the health care provider. Apply pressure to the site and monitor for bleeding.

Notify the health care provider. The nurse would notify the health care provider and plan for imaging studies to assess for a thromboembolism.

Which finding would be most concerning in a patient with hypertensive emergency? Sudden extreme headache with unilateral weakness Mild chest pain with peaked T waves Increased urine output Elevated temperature

Sudden extreme headache with unilateral weakness Hypertensive crisis can cause hemorrhagic stroke, so any sudden neurologic change would be most concerning.