Chapter 31: Assessment and Management of Patients With Hypertension

A nurse providing education about hypertension to a community group is discussing the high risk for cardiovascular complications. Which of the following are risk factors for cardiovascular problems in clients with hypertension? Choose all that apply. 1. Diabetes mellitus 2. Physical inactivity 3. Gallbladder disease 4. Smoking 5. Frequent upper respiratory infections

1. Diabetes mellitus 2. Physical inactivity 4. Smoking

The nurse is completing a cardiac assessment on a patient. The patient has a blood pressure (BP) reading of 126/80. The nurse would identify this blood pressure reading as which of the following? 1. Prehypertension 2. Normal 3. Stage 1 hypertension 4. Stage 2 hypertension

1. Prehypertension

When measuring the blood pressure in each arm of a healthy adult client, the nurse recognizes that which statement is true? 1. Pressures should not differ more than 5 mm Hg between arms. 2. Pressures may vary 10 mm Hg or more between arms. 3. Pressures must be equal in both arms. 4. Pressures may vary, with the higher pressure found in the left arm.

1. Pressures should not differ more than 5 mm Hg between arms.

Prehypertension BP reading

120-139 SBP 80-89 DBP

Stage 1 HTN BP reading

140-159 SBP 90-99 DBP

A nurse is educating a client about monitoring blood pressure readings at home. Which of the following will the nurse be sure to emphasize? 1. "Sit with legs crossed when taking your blood pressure." 2. "Sit quietly for 5 minutes prior to taking blood pressure." 3. "Avoid smoking cigarettes for 8 hours prior to taking blood pressure." 4. "Be sure the forearm is well supported above heart level while taking blood pressure."

2. "Sit quietly for 5 minutes prior to taking blood pressure."

A nurse is discussing with a nursing student how to accurately measure blood pressure. Which of the following points does the nurse emphasize? 1. The size of the cuff does not matter as long as it fits snugly around the arm. 2. A cuff that is too small will give a false high blood pressure. 3. A cuff that is too large will give a false high blood pressure. 4. A cuff that is too small will give a false low blood pressure.

2. A cuff that is too small will give a false high blood pressure.

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? 1. Cardiac catheterization 2. Echocardiography 3. Stress test 4. Tilt-table test

2. Echocardiography

Which of the following would be inconsistent as a component of metabolic syndrome? 1. Hypertension 2. Hypotension 3. Elevated triglyceride levels 4. Abdominal obesity

2. Hypotension

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? 1. Chest pain score of 3 (on a scale of 1 to 10) 2. Numbness and weakness in the left arm 3. Urine output of 40 mL over the past hour 4. Nausea and severe headache

2. Numbness and weakness in the left arm

A patient is brought to the emergency department with complaints 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? 1. Rapidly reduce the blood pressure so the patient will not suffer a stroke. 2. Reduce the blood pressure by 20% to 25% within the first hour of treatment. 3. Reduce the blood pressure by 50% within the first hour of treatment. 4. Reduce the blood pressure to about 140/80 mm Hg.

2. Reduce the blood pressure by 20% to 25% within the first hour of treatment.

Which condition(s) indicates target organ damage from untreated/undertreated hypertension? Select all that apply. 1. Diabetes 2. Stroke 3. Heart failure 4. Retinal damage 5. Hyperlipidemia

2. Stroke 3. Heart failure 4. Retinal damage

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 1. weigh the client. 2. check the client's heart rate. 3. check the client's urine output. 4. check the client's serum K+ level.

2. check the client's heart rate.

The nurse is caring for a patient with systolic blood pressure of 135 mm Hg. This finding would be classified as 1. normal. 2. prehypertension. 3. stage 1 hypertension. 4. stage 2 hypertension.

2. prehypertension.

Which client statement indicates a good understanding of the nutritional modifications needed to manage hypertension? 1. "A glass of red wine each day will lower my blood pressure." 2. "If I include less fat in my diet, I'll lower my blood pressure." 3. "Limiting my salt intake to 2 grams per day will improve my blood pressure." 4. "I should eliminate caffeine from my diet to lower my blood pressure."

3. "Limiting my salt intake to 2 grams per day will improve my blood pressure."

A client with newly diagnosed hypertension asks what she can do to decrease the risk for related cardiovascular problems. Which of the following risk factors is not modifiable by the client? 1. Dyslipidemia 2. Obesity 3. Age 4. Inactivity

3. Age

Which diagnostic method is recommended to determine whether left ventricular hypertrophy has occurred? 1. Blood chemistry 2. Electrocardiography 3. Echocardiography 4. Blood urea nitrogen

3. Echocardiography

Which of the following diagnostic tests may reveal an enlarged left ventricle? 1. Fluorescein angiography 2. Computed tomographic scan 3. Echocardiography 4. Positron emission tomography (PET) scan

3. Echocardiography

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? 1. Primary 2. Essential 3. Secondary 4. Malignant

3. Secondary

The nurse is instructing a client who is newly prescribed an antihypertensive medication. Which nursing instruction is emphasized to maintain client safety? 1. Use a pillbox to store daily medication. 2. Take the medication at the same time daily. 3. Sit on the edge of the chair and rise slowly. 4. Do not operate a motor vehicle.

3. Sit on the edge of the chair and rise slowly.

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? 1. tremor 2. blurred vision 3. dizziness 4. persistent cough

3. dizziness

HTN stats By ethnicity, gender, 1o vs 2o

32.6% of adults in United States; 45.9% of those with poor control Prevalence by gender, ethnicity: 32.9% Caucasian men 30.1% Caucasian women 44.9% African-American men 46.1% African American women 20.6% Hispanic men 29.9% Hispanic women 95% with primary hypertension (unidentified cause) 5% with secondary hypertension (identified cause: renal disease, pregnancy

Which of the following client scenarios would be correct for the nurse to identify as a client with secondary hypertension? 1. A client of advanced age 2. A client with excessive alcohol intake 3. A client experiencing depression 4. A client diagnosed with kidney disease

4. A client diagnosed with kidney disease

A nurse is teaching about lifestyle modifications to a group of clients with known hypertension. Which of the following statements would the nurse include in the education session? 1. Limit alcohol consumption to no more that 3 drinks per day. 2. Maintain a waist circumference of 45 inches (114 cm) (men) and 40 inches (102 cm) (women) or less. 3. Maintain a body mass index between 30 and 35. 4. Engage in aerobic activity at least 30 minutes/day most days of the week.

4. Engage in aerobic activity at least 30 minutes/day most days of the week.

The nurse is caring for a client with accelerated hypertension. Which body system would the nurse assess to identify early signs of blood pressure progression? 1. Kidney 2. Heart 3. Musculoskeletal system 4. Eyes

4. Eyes

When teaching a patient about hypertension and lifestyle changes the nurse emphasizes that which of the following should be included in the diet? 1. Whole milk and cheeses 2. A glass of red wine 3. Chloride-containing foods 4. Fresh fruits and vegetables

4. Fresh fruits and vegetables

It is important for the nurse to encourage the patient to rise slowly from a sitting or lying position because: 1. Gradual changes in position provide time for the heart to reduce its rate of contraction to resupply oxygen to the brain. 2. Gradual changes in position help reduce the blood pressure to resupply oxygen to the brain. 3. Gradual changes in position help reduce the heart's work to resupply oxygen to the brain. 4. Gradual changes in position provide time for the heart to increase rate of contraction to resupply oxygen to the brain.

4. Gradual changes in position provide time for the heart to increase rate of contraction to resupply oxygen to the brain.

A nurse is educating about lifestyle modifications for a group of clients with newly diagnosed hypertension. While discussing dietary changes, which of the following points would the nurse emphasize? 1. There is usually no need to change alcohol consumption for clients with hypertension. 2. A person with hypertension should never consume alcohol. 3. The taste buds never adapt to decreased salt intake. 4. It takes 2 to 3 months for the taste buds to adapt to decreased salt intake.

4. It takes 2 to 3 months for the taste buds to adapt to decreased salt intake.

A nurse is discussing with a group of nursing students how to accurately measure blood pressure. The nurse is sure to include all the following information except: 1. Routinely calibrate the sphygmomanometer. 2. Center the cuff bladder directly over the brachial artery. 3. Initially take the blood pressure in both arms. 4. Position the forearm above the level of the heart.

4. Position the forearm above the level of the heart.

A patient is taking amiloride (Midamor) and lisinopril (Zestril) for the treatment of hypertension. What laboratory studies should the nurse monitor while the patient is taking these two medications together? 1. Magnesium level 2. Sodium level 3. Calcium level 4. Potassium level

4. Potassium level

Normal BP reading

<120 SBP <80 DBP

Stage II HTN BP Reading

>160 SBP >100 DBP

Nursing Process Assessment Diagnosis Planning & Goals Interventions Evaluation

Assessment Parameters for measuring blood pressure - Chart 31-2, p. 894 Comprehensive systems assessment Adherence to medication regimen Diagnosis Nursing diagnoses Knowledge deficit/patient education Non-adherence to therapeutic regimen Planning and Goals Patient understanding of disease and treatment Patient participation in self-care No complications Interventions Patient education for full plan of care Referral to sites for education materials Rebound hypertension Adherence to plan - data show poor adherence: 50% stop medication in 1 year; 54% achieve control Monitoring for potential complications Evaluation- Expected Patient Outcomes Maintains tissue perfusion No signs of impairment Complies with self-care regimen Modifies risk factors Adheres to plan of care Experiences no complications No signs of organ damage

HTN Pathophysiology

Blood pressure = product of cardiac output multiplied by peripheral resistance Cardiac output = product of heart rate multiplied by stroke volume ↑ Cardiac output or ↑ peripheral resistance can → hypertension Increased sympathetic nervous system Increased renal absorption of sodium Expansion of extracellular fluid volume Decreased vasodilation of arterioles Resistance to insulin action

Sequelae of HTN

Blood vessel damage: heart, kidney, brain, eyes Organ damage: MI, stroke, renal failure, impaired vision, heart failure Blood pressure control is critical

What is the most common chronic disease in the US

HTN

Physical/Diagnostic Assessment

History and Physical Exam Laboratory tests Urinalysis Blood chemistry Cholesterol levels ECG Echocardiogram

HTN Crisis Emergency vs urgency

Hypertensive emergency Elevated blood pressure to > 180 SBP and/or > 120DBP Must be lowered immediately to prevent organ damage Acute, life-threatening episodes: pregnancy, MI, dissecting AAA, intracranial hemorrhage Reduction of blood pressure by 25% within 1 hour Administration of IV medications Close monitoring of blood pressure changes Hypertensive urgency Blood pressure elevated but without evidence of impending organ damage Associated with severe headaches, nosebleeds, anxiety Oral doses of fast-acting agents Close monitoring of blood pressure changes Goal: normalize blood pressure within 24 to 48 hours

HTN Common Problems

Left ventricular hypertrophy Myocardial infarction Heart failure Transient ischemic attack (TIA) Cerebrovascular disease (stroke) Renal insufficiency Chronic kidney disease Retinal hemorrhage

Medical Management Pharmacological Gerontological

Pharmacological Decrease peripheral resistance Decrease blood volume Decrease strength/rate of myocardial contraction Medications - Table 31-4, pp. 890-893 Gerontological Management follows similar protocol Attention to medication choices Attention to barriers to therapy

Stages of HTN Tx at each stage Inc risk for what

PreHTN-intended to alert person and care giver to risk of progressing to Stage I and Stage II modify risk behaviors, LIFESTYLE CHANGES Stage I-initiate treatment with medications Inc risk for: stroke, MI, heart failure, death, atherosclerotic heart disease

Epidemiology of HTN Risk factors Effective tx

Risk: Premature death Disability If not treated, related to: myocardial infarction; heart failure; stroke; chronic kidney disease Effective tx: Lifestyle changes (diet, exercise, smoking cessation) Medication regimens

HTN Risk factors

Stress Diabetes mellitus Smoking Chronic kidney disease Obesity Dyslipidemia Physical inactivity Family history Older age Alcohol consumption

Gerontological issues

Structural changes in heart and blood vessels Atherosclerotic plaque Impaired vasodilation Decreased elasticity of blood vessels Aorta, large arteries - problems with stroke volume Elevated systolic pressure, normal diastolic Isolated systolic hypertension High morbidity, mortality

Definition of HTN and diagnosis

Systolic blood pressure reading > 140 mm Hg Diastolic blood pressure reading > 90 mm HG 2 average or more BP measurements during 2 or more contacts with HCP

HTN Clinical Manifestations

Usually NO symptoms other than elevated blood pressure Symptoms related to organ damage - seen late and are serious Retinal and other eye changes Renal damage Myocardial infarction Cardiac hypertrophy Stroke

Medical Management

Weight reduction DASH - Dietary Approaches to Stop Hypertension (Table 31-3, p. 889) Reduction in dietary sodium Physical activity Moderation of alcohol consumption

isolated systolic hypertension

a condition most commonly seen in the older adult in which the systolic pressure is greater than 140 mm Hg and the diastolic pressure is less than 80 mm Hg

hypertensive emergency

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

hypertensive urgency

a situation in which blood pressure is severely elevated but there is no evidence of impending or progressive target organ damage

dyslipidemia

abnormal blood lipid levels, including high total, low-density lipoprotein, and triglyceride levels as well as low high-density lipoprotein levels

rebound hypertension

blood pressure that is controlled with medication and becomes uncontrolled (abnormally high) with the abrupt discontinuation of medication

primary hypertension

denotes high blood pressure from an unidentified cause; also called essential hypertension

secondary hypertension

high blood pressure from an identified cause, such as kidney disease

monotherapy

medication therapy with a single agent