Exam 2

The nurse is caring for a patient newly diagnosed with hypertension. Which of the following statements if made by the patient indicates the need for further teaching?

"If I take my blood pressure and its normal, I dont have to take my BP pills."

A group of student nurses are practicing taking blood pressure. A 56-year old male student has a blood pressure reading of 146/96 mm Hg. Upon hearing the reading, he exclaims, "my pressure has never been this high. Do you think my doctor will prescribe medication to reduce it?" Which of the following responses by the nursing instructor would be best?

A single elevated blood pressure does not confirm hypertension. You will need to have your blood pressure measured several times before a diagnosis can be made.

Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute shortness of breath has heart failure?

B-type natriuretic peptide

The nurse is providing discharge education to a client diagnosed with heart failure. What should the nurse teach the client to do to assess fluid balance in the home setting?

Monitor weight daily

The nurse observes a certified nursing student (CNA) obtaining a blood pressure reading with a cuff that is too small for the patient. The nurse informs the CNA that using a cuff that is too small can affect the reading results in what way?

The results will be falsely elevated

The nurse assess that a home hospice patient with terminal cancer who complains of severe pain has respiratory rate of 11 breaths/min. What action should the nurse take?

Titrate the prescribed morphine dose up until the patient indicates adequate pain relief

According to the classification of hypertension diagnosed in the older adult, hypertension that can be attributed to an underlying cause it termed

secondary

Which of the following medications are routinely used in the treatment of hypertension? SATA

- Telmisartan - Amlodipine - Hydrochlorothiazide - Ramirpil ** All the answers beside "clopidogrel

Propanolol is prescribed to treat the patients hypertension. The nurse should consult with the health care provider before giving the drug when the patient reveals which of the following history?

Asthyma/COPD

Which nursing action could the nurse delegate to unlicensed assistive personnel (UAP) when caring for a patient who is using a fentanyl patch and a heating pad for treatment of chronic back pain?

Count the respiratory rate every 2 hours

The nurse is providing client education prior to a clients discharge home after treatment for heart failure . What should the nurse include in the discharge teaching?

How to recognize the signs and symptoms of worsening heart failure

Which information is most important for the nurse to include when teaching a patient with newly diagnosed hypertension?

Hypertension is known as a "silent killer" there are no symptoms until target organ damage occurs

The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best indicator that the treatment has been effective?

Reduced dyspnea with the head of the bed at 30 degrees

While admitting an 82-year old patient with acute decompensated heart failure to the hospital , the nurse learns that the patient lives alone and sometimes confuses the "water pill" with the "heart pill." What should the nurse include in the discharge plan?

Referral to a home health care agency

A client is placed on a low sodium (500 mg/day) diet. Which client statement indicates that the nurses nutrition teaching has been effective?

"I choose broiled chicken with a baked potato for dinner"

Regarding hemodynamics and blood pressure, which of the following statements is false?

An increase in Systemic Vascular Resistance (SVR) will cause a **decrease** in blood pressure

The nurse is caring for a patient who had abdominal surgery yesterday and is receiving morphine through patient-controlled analgesia. What action by the nurse is a priority?

Checking the respiratory rate

The nurse working on the heart failure unit knows that teaching an older female patient with newly diagnosed heart failure was successful when the patient states that

she will call the clinic if her weight goes

Which of the following terms is given to hypertension in which blood presssure that is controlled with therapy becomes uncontrolled (abnormally high) with the discontinuation of therapy?

Rebound

A nurse is assisting with checking blood pressure at a local health care fair. To which client would the nurse pay particular attention?

A 40-year-old African American man

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

A family history of hypertension

A female client, aged 82, visits the clinic for a blood pressure (BP) check. Her hypertension is not well controlled and new blood pressure medicine is prescribed. What is important for the nurse to teach this client about her blood pressure medicine

A possible adverse effect of blood pressure medicine is dizziness when you stand

During a visit to a 78-year-old patient with chronic heart failure, the home care nurse finds that the patient has ankle edema, a 2-kg weight gain, over the past 2 days and complains of "feeling too tired to get out of bed." Based on these data, a correct nursing diagnosis for the patient is

Activity intolerance related to fatigue

Which topic will the nurse plan to include in discharge teaching for a patient with heart failure with reduced ejection fraction (HFrEF) ?

Benefits and side effects of angiotermin-converting enzyme (ACE) inhibitors

A patient who has good control for chronic pain using a fentanyl patch around the clock, reports rapid-onset pain at level 9 and requests "something for pain that will work quickly" How will the nurse document the type of pain reported by this patient ?

Breakthrough pain

A 77-year-old client has newly diagnosed stage 2 hypertension. The physician has prescribed the client a thiazide and an angio-converting enzyme inhibitor. The nurse is concerned about postural hypotension. Which of the following will the nurse be sure to include in eduction for the client.

Change positions (lying or sitting to standing) slowly.

A client has just been diagnosed with elevated blood pressure. What would the nurse instruct this client to do to restore his blood pressure below elevated levels?

Decrease sodium intake

The nurse is caring for a client whose medical history includes chronic fatigue and poorly controlled back pain. These medical diagnoses should alert the nurse to the possibility of which major health problem?

Depression

A patient with chronic neck pain is seen in the pain clinic for follow-up. To evaluate whether pain management is effective, which question is best for the nurse to ask ?

Does the pain keep you from activities that you enjoy?

A nurse educator is providing information about hypertension to a small group of clients. A participant asks what she can do to decrease her blood pressure and thus her risk for heart problems. The nurse describes modifiable and non-modifiable risk factors. Which of the following risk factors can the client modify?

Dyslipidemia

A nurse is teaching about lifestyle modification to a group of clients with known hypertension. Which of the following statements would the nurse include in the education session.

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

The nurse administers morphine to a patient with severe pain. Fifteen minutes later, the nurse returns and asks the patient if the pain medication was effective? Which step of the nursing process does this reflect?

Evaluation

The staff educator is teaching ED nurses about hypertensive crisis. The nurse educator should explain that hypertensive urgency differs from hypertensive emergency in what way?

Hypertensive emergencies are associated with evidence of target organ damage.

A nurse is assessing a patient with left and right sided heart failure for signs and symptoms of fluid volume overload. the nurse would not expect to find which of the following manifestations?

Hypovolemia

While answering an older adult patient, the nurse notes jugular venous distention (JVD) with the head of the patients bed, elevated 45 degrees. What does this finding indicate?

Increased right atrial pressure

A client experiences orthostatic hypertension while receiving furosemide (Lasix) to treat hypertension. How should the nurse intervene?

Instruct the client to sit for several minutes before standing

What response is appropriate when a client with hypertension divulges that she does not take prescribed antihypertensive medications because she does not experience any symptoms

Let her know thats why hypertension is known as "the silent killer"

A client hospitalized for treatment of hypertension is being prepared for discharge. Which teaching topic should the nurse be sure to cover?

Maintaining a low sodium diet

A patient who is receiving dobutamine for the treatment of acute decompensated heart failure (ADHF) has the following nursing interventions included in the plan of care. Which action will be most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/ vocational nurse (LPN/VN)?

Monitor the patient blood pressure and heart rate every hour.

Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires the most immediate action by the nurse?

O2 Saturation of 88%

An unlicensed nursing assistant (NA) reports to the nurse that a postsurgical patient is complaining of pain that she rates as 8 on a 0-to-10 point scale. The NA tells the nurse that he thinks the patient is exaggerating and does not need pain medication. What is the nurse's best response? \

Pain is "whatever the person experiencing the pain says it is, existing whenever the person says it does.

A patient has been prescribed anti-hypertensives. After assessment and analysis , the nurse has identified a nursing diagnosis of risk for ineffective health maintenance related to non-adherence to therapeutic regimen. When planning this patient' care, what desired outcome should the nurse identify?

Patient takes medication as prescribed and reports any adverse effects

During the physical assessment of a client with hypertension, what would you expect to be the most obvious finding?

Sustained increase of either one or both systolic or diastolic measurements

An older patient has been diagnosed with possible white coat hypertention. Which action by the nurse best addresses the form of hypertension?

Teach the patient how to self monitor and record blood pressure at home.

A client presents with intense back pain rating 11 on the 0-10 scale. he is hunched over and reports that the pain is running down his legs. What information will the nurse inquire about while obtaining the history of the present health concern?

The clients activity just prior to the onset of pain

During the change of shift report, the nurse obtains the following information about a patient with hypertension, who received the first dose of nadolol during the previous shift. Which of the following information requires immediate intervention?

The patient has resp. rate of 28 and developed wheezes through the lung fields

When teaching a patient about hypertension and lifestyle changes the nurse emphasizes that which of the following should be included in diet?

fresh fruits and vegetables

The charge nurse observes a new registered nurse doing discharge teaching for a patient with hypertension who has a new prescription for enatapril (Vasotec). The charge nurse will need to intervene if the new RN tells the patient to

increase the dietary intake of high potassium foods

The nurse is assessing a client with right-sided heart failure. What assessment finding is most consistent with this clients diagnosis.

jugular vein distention

Which of the following factors does not directly influence blood pressure?

lipid levels