Chapter 27: Caring for Clients with Hypertension

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." 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.

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 client with newly diagnosed hypertension has come to the clinic for a follow-up visit. The client asks the nurse why she has to come in so often. What would be the nurse's best response?

"We do this to make sure your health is stable. We'll then monitor it at routinely scheduled intervals." 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 clients. The client must not change medication doses unilaterally.

A nurse is discussing with a nursing student how to accurately measure blood pressure. What statement by the student indicates an understanding of the education?

A cuff that is too small will give a false high blood pressure. Using a cuff that is too small will give a false high blood pressure measurement, while using a cuff that is too large results in a false low blood pressure measurement.

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 client in hypertensive emergency is being cared for in the ICU. The client has become hypovolemic secondary to natriuresis. What is the nurse's most appropriate action?

Administer normal saline IV, as prescribed. 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 given. Sodium administration, cessation of antihypertensive therapy, and administration of vasoconstrictors are not normally indicated.

The nurse is providing care for a client with a diagnosis of hypertension. The nurse should consequently assess the client for signs and symptoms of which other health problem?

Atherosclerosis 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.

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 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 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 client's care, what desired outcome should the nurse identify?

Client takes medication as prescribed and reports any adverse effects. The most appropriate expected outcome for a client 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 client's role in the treatment regimen.

A client has been diagnosed as being prehypertensive. What should the nurse encourage this client to do to aid in preventing a progression to a hypertensive state?

Exercise on a regular basis. 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 clients to limit their activity in the morning or to avoid potassium and protein intake.

A client experiences orthostatic hypotension while receiving furosemide to treat hypertension. How will the nurse intervene?

Instruct the client to sit for several minutes before standing. To minimize the effects of orthostatic hypotension, the nurse should instruct the client to rise slowly, such as by sitting for several minutes before standing. Administering I.V. fluids would be inappropriate (unless the client were dehydrated) because doing so would counteract the effects of furosemide and could cause fluid imbalance. Administering a vasodilator, isosorbide, would further reduce the client's blood pressure, worsening orthostatic hypotension. Inserting an indwelling urinary catheter would make it easier to monitor urine output, but wouldn't minimize the effects of orthostatic hypotension.

The nurse is screening a number of adults for hypertension. What range of blood pressure is considered normal?

Less than 120/80 mm Hg 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.

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 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 patient comes to the walk-in clinic. While assessing the patient's vital signs, the nurse assesses the patient's blood pressure at 128/89 mm Hg. According to JNC7, how would this patient's blood pressure be classified?

Prehypertensive JNC7 defines a blood pressure of less than 120/80 mm Hg diastolic as normal, 120 to 129/80 to 89 mm Hg as prehypertension, and 140/90 mm Hg or higher as hypertensive.

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.

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.

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 Risk factors for cardiovascular problems in clients with hypertension include smoking, dyslipidemia, diabetes mellitus, impaired renal function, obesity, physical inactivity, age, and family history.

Mr. Faulkner is a 69-year-old man who has enjoyed generally good health for his entire adult life. As a result, he has been surprised to receive a new diagnosis of hypertension after a series of visits to his primary care provider. The nurse who is working with Mr. Faulkner should recognize which of the following aspects of aging and hypertension?

The incidence and prevalence of hypertension increase with age. The prevalence of hypertension increases with aging. Aging causes structural and functional changes in the heart and blood vessels, including atherosclerosis and decreased elasticity of the major blood vessels. The diagnostic criteria between older and younger adults do not differ. Older adults are not more immune to the damaging effects of high blood pressure.

A client newly diagnosed with hypertension is discussing risk factors with the nurse. The nurse talks about lifestyle changes with the client and advises that the client should avoid tobacco use. What is the primary rationale behind that advice to the client?

Tobacco use increases the client's concurrent risk of heart disease. Smoking increases the risk for heart disease, for which a client 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.

A patient has come to the clinic for a follow-up assessment. Before taking the blood pressure, the nurse should determine if the patient has:

Tried to rest quietly for 5 minutes before the reading is taken Prior to the nurse assessing the patient's blood pressure, 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. The patient does not need to be NPO for at least 8 hours.

The nurse is discussing the role of lifestyle modifications with a patient who has a diagnosis of primary hypertension. Which of the following lifestyle modifications typically results in the greatest reduction in blood pressure (BP)?

Weight loss Research has demonstrated that a weight loss of only 10 pounds may result in a 5 to 20 mm Hg reduction in systolic BP, offering tangible results to the patient. Limiting alcohol and sodium intake are important lifestyle modifications, but neither causes as large an effect on BP as weight loss. Blood pressure monitoring is important but does not directly cause a reduction in blood pressure.

A client has been diagnosed as experiencing "white-coat hypertension." This refers to:

anxiety "White-coat hypertension" is a term describing anxiety that results in elevated BP. It occurs when patients are being evaluated by medical personnel who traditionally have worn a white coat.

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. 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 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.

A client with secondary hypertension has come into the clinic for a routine check-up. When comparing this client's diagnosis to primary hypertension, the nurse recognizes that secondary hypertension:

has a specific cause. 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.

The nurse is reviewing the diet of a client who has been diagnosed with hypertension. The nurse recommends reducing or avoiding caffeine because caffeine:

increases the heart rate and causes vasoconstriction. The nurse recommends reducing or avoiding caffeine for clients with hypertension because caffeine increases the heart rate and causes vasoconstriction. Angina and coronary artery disease are the result of arteries becoming blocked by a substance called plaque.

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. 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.

A client who was recently diagnosed with prehypertension is to meet with a dietitian and return for a follow-up with the cardiologist in 6 months. What would this client's treatment likely include?

nonpharmacological interventions Nonpharmacologic interventions are used for clients with prehypertension.

A client who is newly diagnosed with high blood pressure has a 20-pack-year tobacco history. The nurse recommends smoking cessation for this client because nicotine:

raises heart rate, constricts arterioles, and reduces the heart's ability to eject blood. Nurses recommend smoking cessation for clients with hypertension because nicotine raises the heart rate, constricts arterioles, and reduces the heart's ability to eject blood.

Hypertension that can be attributed to an underlying cause is termed

secondary hypertension. Secondary hypertension may be caused by a tumor of the adrenal gland (e.g., pheochromocytoma). Primary, or essential, hypertension has no known underlying cause. Isolated systolic hypertension is demonstrated by readings in which the systolic pressure exceeds 140 mm Hg and the diastolic measurement is normal or near normal (less than 90 mm Hg).

The nurse is caring for a patient with systolic blood pressure of 135 mm Hg. This finding would be classified as

stage 1 hypertension. 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 performing blood pressure screenings at a local health fair. While obtaining subjective assessment data from a client with hypertension, the nurse learns that the client has a family history of hypertension and she herself has high cholesterol and lipid levels. The client says she smokes one pack of cigarettes daily and drinks "about a pack of beer" every day. The nurse notes what nonmodifiable risk factor for hypertension?

A family history of hypertension Unlike cholesterol levels, alcohol intake, and adherence to treatment, family history is not modifiable.

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 Age and family history for cardiovascular disease are risk factors that cannot be changed. Obesity, inactivity, and dyslipidemia are risk factors that can be improved by the client through dietary changes, exercise, and other healthy lifestyle choices.

An older adult is newly diagnosed with primary hypertension and has just been started on a beta-blocker. What should the nurse include in health education?

Use of strategies to prevent falls stemming from postural hypotension Older adults have impaired cardiovascular reflexes and are more sensitive to postural hypotension. The nurse teaches clients to change positions slowly when moving from lying or sitting positions to a standing position, and counsels elderly clients 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, are strongly recommended. Increasing fluids in elderly clients may be contraindicated due to cardiovascular disease. Increased intracranial pressure is not a risk and activity should not normally be limited.

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

obesity hypertension family history of early cardiovascular events diabetes 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.

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.