Med Surg 27
The nurse and a dietitian are instructing the client on a low-sodium diet needed to lower the blood pressure. Which question, asked by the nurse, is most important? A) "Who eats meals with you?" B) "How do you prepare your food?" C) "Do you each three meals per day?" D) "Do you snack in the evening?"
B Feedback: Asking the client how food is prepared, gives the nurse and dietitian the ability to judge the sodium content. If the client opens cans of food, typically, there will be elevated sodium content. If the client uses prepared foods or eats out regularly, there is sodium in the content. If the client uses fresh ingredients, sodium content is minimal. Asking about who eats with the client and their eating patterns are not as helpful in determining sodium content. 30
The nurse is working on a busy cardiac unit caring for four hypertensive clients. Which client description would the nurse assess first because the client is at an increased risk for malignant hypertension? A) A client with anorexia and history of no healthcare insurance B) A client with liver dysfunction who drinks alcohol daily C) A schizophrenic residing at an assisted living facility D) A client with chronic asthma who uses a corticosteroid inhaler
A Feedback: Accelerated and malignant hypertension can occur in individuals who fail to maintain follow-up or comply with medical therapy. Those individuals who have no healthcare insurance often are unable to obtain the medical follow-up or afford the cost of medications to treat the hypertensive state. If the hypertension is untreated, symptoms and complication can rapidly follow. The other choices need further assessment but are not the priority. 26
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? A) Eyes B) Kidney C) Heart D) Musculoskeletal system
A Feedback: Accelerated hypertension is defined as a markedly elevated blood pressure with symptoms of hemorrhages and exudates in the eyes. If the hypertension is untreated, accelerated hypertension progresses to malignant hypertension with symptoms of papilledema. Long-standing hypertension can produce changes in the kidney, heart, and musculoskeletal system. 25
What is blood pressure? A) The force produced by the volume of blood in arterial walls B) The force produced by the volume of blood in the venous system C) The measurement of cardiac output D) The peripheral resistance of the cardiac output
A Feedback: Blood pressure (BP) is the force produced by the volume of blood in arterial walls. It is represented by the formula: BP = CO (cardiac output) × PR (peripheral resistance). This makes options B, C, and D incorrect. 7
Which of the following diagnostic tests may reveal an enlarged left ventricle? A) Echocardiography B) Computed tomographic scan C) Fluorescein angiography D) Positron emission tomography (PET) scan
A Feedback: Echocardiography reveals an enlarged left ventricle. Fluorescein angiography reveals leaking retinal blood vessels, and a PET scan is used to reveal abnormalities in blood pressure. A CT scan reveals structural abnormalities. 4
The nurse is employed in a physician's office and is caring for a client present for an annual exam. A blood pressure of 124/84 mm Hg is documented. Following revised guidelines for identifying hypertension, which educational pamphlet is help? A) Increasing fluids for low blood pressure B) Stress reduction to lower prehypertensive state C) Use of beta-blockers for treatment of hypertension D) Diagnostic testing for determining cardiac functioning
B Feedback: A blood pressure of 124/84 mm Hg is now considered to be in the lower range of prehypertension. Knowledge of stress reduction may be helpful in lowering the blood pressure without medication therapy. A blood pressure of 124/84 mm Hg is not considered a low blood pressure or in need of medication therapy due to hypertension. Diagnostic testing for cardiac functioning is not typical for a client with prehypertension. 16
A client has just been diagnosed with prehypertension. What would the nurse instruct this client to do to restore his blood pressure below hypertensive levels? A) Increase iodine intake. B) Decrease sodium intake. C) Increase fluid intake. D) Avoid over-the-counter decongestants.
B Feedback: The nurse should instruct clients with prehypertension to avoid or decrease sodium and iodine intake. Increasing fluid intake raises circulating blood volume and systemic vascular resistance. Over-the-counter decongestants decrease pulmonary congestion and not hypertension. 2
A client, newly prescribed a low-sodium diet due to hypertension, is asking for help with meal choices. The client provides four meal choices, which are favorites. Which selection would be best? A) Toasted cheese sandwich on whole wheat toast with tomato soup B) Creamed chipped beef over toast with mashed potatoes C) Hot dog with ketchup and relish on whole wheat bun D) Green pepper stuffed with diced tomatoes and chicken
D Feedback: Fresh vegetables are low in sodium with diced tomatoes (fresh) and chicken is a good low-sodium, high vegetable and protein selection. Cheese and soup (tomato and creamed) are high in sodium. Processed meats such as a hot dog and condiments such as ketchup are high in sodium. 31
The nurse in an oncology clinic notes that the client being treated has hypertension. What tumor is a predisposing condition for secondary hypertension? A) Pheochromocytoma B) Wilms' tumor C) Astrocytoma D) Lymphoma
A Feedback: Predisposing conditions include kidney disease, pheochromocytoma (a tumor of the adrenal medulla), hyperaldosteronism (increased secretion of mineralcorticoid by the adrenal cortex), atherosclerosis, use of cocaine or other cardiac stimulants (e.g., weight-control drugs, caffeine), and use of oral contraceptives. Wilms' tumors, astrocytomas, and lymphomas are not predisposing conditions for secondary hypertension. 9
Which of the following is the nurse most correct to recognize as a direct effect of client hypertension? A) Renal dysfunction resulting from atherosclerosis B) Anemia resulting from bone marrow suppression C) Hyperglycemia resulting from insulin receptor resistance D) Emphysema related to poor gas exchange
A Feedback: 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. 19
A nurse is assessing the blood pressure of a large adult client diagnosed with primary hypertension. To ensure an accurate blood pressure reading, the nurse follows which standard of care? Select all that apply. A) Use the large adult blood pressure cuff. B) Place the cuff midway between the acromion and olecranon process. C) Vary the blood pressure reading sites every other day. D) Obtain supine, sitting, and standing readings daily. E) Document the results immediately after the reading is completed.
A, B, E Feedback: Standards of care require that the nurse use the proper-sized blood pressure cuff placed at the proper location on the arm at the appropriate time. Using a large adult blood pressure cuff is the correct size. Placing the cuff between the acromion process and olecranon process is the correct site. Documenting the blood pressure reading accurately after obtaining the reading is correct. Varying the blood pressure site and positioning every 1 or 2 days provides varied readings. Consistency needs to be maintained to draw accurate conclusions. 24
The nurse is volunteering at a community blood pressure screening. A client, never diagnosed with hypertension, presents with a blood pressure of 158/90 mm Hg. Which assessment questions, asked by the nurse, are appropriate? Select all that apply. A) "Have you recently drunk a caffeinated beverage?" B) "Did you have a beer after work?" C) "Do you smoke?" D) "Do you have a friend accompanying you?" E) "Are you married and with children?"
A, C Feedback: At a community blood pressure clinic, the nurse would assess for common factors for a blood pressure to be elevated. Factors that can affect blood pressures readings include smoking or drinking coffee within 30 minutes of the reading. One beer after work should not affect the blood pressure reading, and some individuals may find it relaxing. Social situations are difficult to assess in a community blood pressure clinic. The client would be referred to having another blood pressure reading and, if elevated, referred to a physician. 28
The nurse is screening a client at a health fair for hypertension. Which assessment data, provided by the client, would prompt the nurse to stress physician involvement? Select all that apply. A) Fatigue B) Constipation C) Headache D) Insomnia E) Dysuria F) Blurred vision
A, C, D, F Feedback: When assessing the client for symptoms of hypertension, the nurse should recognize that the client may note fatigue, headache, insomnia, and blurred vision. Other symptoms include dizziness, nervousness, nosebleeds, angina, and dyspnea. Constipation and dysuria are not signs of hypertension. 20
The nurse is caring for a client who is ordered Hyperstat IV to decrease blood pressure. Which nursing consideration is a priority? A) Elevate the head of the bed. B) Use an automatic blood pressure recording machine. C) Place a Foley catheter to monitor urine output. D) Assess the client's deep tendon reflex.
B Feedback: A nursing priority is to monitor the client's blood pressure every few minutes. It is unrealistic to have the nurse manually assess the blood pressures. An automatic blood pressure machine is programed to assess the blood pressure and record the results for assessment. The other options may be completed; however, monitoring the blood pressure is the priority. 27
A female client, aged 82 years, visits the clinic for a blood pressure (BP) check. Her hypertension is not well controlled, and a new blood pressure medicine is prescribed. What is important for the nurse to teach this client about her blood pressure medicine? A) Take the medicine on an empty stomach. B) A possible adverse effect of blood pressure medicine is dizziness when you stand. C) There are no adverse effects from blood pressure medicine. D) A severe drop in blood pressure is possible.
B Feedback: A possible adverse effect of all antihypertensive drugs is postural hypotension, which can lead to falls. Teaching should include tips for managing syncope and dizziness. You would not teach the client to take the medicine on an empty stomach. 5
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? A) Lung and arteries B) Heart and blood vessels C) Brain and sympathetic nervous system D) Kidneys and autonomic nervous system
B Feedback: 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. 12
The nurse is working on a clinical research study, obtaining data evaluating central aortic systolic pressure and brachial arm systolic pressure. The client notes difference in the readings. Which response by the nurse is most accurate? A) "The difference is due to machine calibration." B) "The difference is due to the location of pressure measurement." C) "The difference is due to the discomfort caused by the measurement procedure." D) "The difference is due to the constrictive force on the arteries when the measurement is taken."
B Feedback: Central aortic systolic pressure results, reflecting pressure at the root of the aorta, can be documented as 30 mm Hg lower than when corresponding results obtained at the brachial arm. The differences are not due to machine calibration, discomfort, or constriction of the arteries. 15
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? A) The kidney retains sodium and water. B) The kidney excretes sodium and water. C) The kidney retains sodium and excretes water. D) The kidney retains water and excretes sodium.
B Feedback: 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. 33
Which of the following client scenarios would be correct for the nurse to identify as a client with secondary hypertension? A) A client experiencing depression B) A client diagnosed with kidney disease C) A client of advanced age D) A client with excessive alcohol intake
B Feedback: Secondary hypertension is an elevated blood pressure that results from or is secondary to some other disorder such as kidney disease, a tumor of the adrenal medulla, or atherosclerosis. Depression alone is typically not associated with hypertension. Advanced age and alcohol intake are considered factors for essential hypertension. 17
The nurse is caring for a client with hypertension. The nurse is correct to realize that a 24-hour urine is ordered to determine if the cause of hypertension is related to the dysfunction of which of the following? A) The thyroid gland B) The adrenal gland C) The pituitary gland D) The thymus
B Feedback: The 24-hour urine collection specimen is ordered to determine dysfunction of the adrenal gland. The 24-hour urine detects elevated catecholamines. The other options are not evaluated by a 24-hour urine.
The nurse is evaluating the types of medications prescribed for a client's hypertension. Which of the following medication classifications establishes an action on vasoconstrictive hormones in the blood stream? A) Beta-blocker B) ACE inhibitor C) Loop diuretic D) Calcium channel blocker
B Feedback: The angiotensin-converting enzyme (ACE) inhibitor's primary action is to prevent the conversion of angiotensin I to angiotensin II, a potent vasoconstricting hormone in the blood. A beta-blocker blocks the beta-adrenergic receptors decreasing sympathetic nervous system stimulation. Loop diuretics excrete water from the loop of Henle, reducing circulating blood volume. Calcium channel blockers dilate coronary and peripheral arteries. 29
The nurse is caring for a client with malignant hypertension. What would be an appropriate nursing intervention for this client? A) Monitor the client's mental and emotional status every hour. B) Monitor the blood pressure (BP) every few minutes by applying an automatic BP recording machine. C) Monitor the client's blood sugar every hour. D) Monitor the client's temperature every few minutes.
B Feedback: The nurse applies an automatic BP recording machine to the arm to measure the BP every few minutes. The nurse also keeps emergency equipment and drugs ready in case complications develop. Monitoring the client's mental and emotional status, blood sugar, or temperature every few minutes will not reflect the sudden rise in BP of a client with malignant hypertension. 3
The physician is ordering a test for the hypertensive client that will be able to evaluate whether the client has experienced heart damage. Which diagnostic test would the nurse anticipate to determine heart damage? A) Blood chemistry B) Multiple gated acquisition scan (MUGA) C) Chest radiograph D) Fluorescein angiography
B Feedback: The nurse realizes that undiagnosed (untreated), long-standing hypertension can cause heart damage. The diagnostic test that best determines heart damage is the multiple gate acquisition scan (MUGA). This test is used to detect how efficiently the heart pumps. A blood chemistry determines electrolyte balance. A chest radiograph (chest x-ray) can provide details of the heart size through shading on the scan. Fluorescein angiography is an ophthalmologic test revealing leaking retinal blood vessels. 23
The nurse is instructing a client who is newly prescribed an antihypertensive medication. Which nursing instruction is emphasized to maintain client safety? A) Use a pillbox to store daily medication. B) Sit on the edge of the chair and rise slowly. C) Do not operate a motor vehicle. D) Take the medication at the same time daily.
B Feedback: The nursing instruction emphasized to maintain client safety is to sit on the edge of the chair before rising slowly. By doing so, the client reduces the possibility of falls related to postural hypotension. Using a pillbox to store medications and taking the medication at the same time daily is good medication management instruction. There is no reason when taking antihypertensive medications to restrict driving. 22
You are part of a group of nursing students who are making a presentation on chronic hypertension. What is one subject you would need to include in your presentation as a possible consequence of untreated chronic hypertension? A) Peripheral edema B) Right-sided heart failure C) Stroke D) Pulmonary insufficiency
C Feedback: A stroke occurs if vessels in the brain rupture and bleed. If an aneurysm has developed in the aorta from chronic hypertension, it may burst and cause hemorrhage and shock. Options A, B, and D are not usually consequences of untreated chronic hypertension. 10
The nurse is obtaining a healthy history from a client with blood pressure of 146/88 mm Hg. The client states that lifestyle changes have not been effective in lowering the blood pressure. Which medication classification does the nurse anticipate first? A) ACE inhibitors B) Beta-blocker C) Thiazide diuretic D) Calcium channel blocker
C Feedback: Clients with hypertension, unable to be lowered by lifestyle changes, usually are placed on a thiazide diuretic initially. However, most people with hypertension will need two or more antihypertensive medications to reduce their blood pressure. 21
The nurse obtains a blood pressure of 136/86 mm Hg on morning assessment of a client with history of hypertension. Which pressure is of most concern when considering ventricular relaxation? A) Central aortic pressure B) Systolic pressure C) Diastolic pressure D) Central venous pressure
C Feedback: Diastolic blood pressure reflects arterial pressure during ventricular relaxation. It depends on the resistance of the arterioles and the diastolic filing times. Central aortic pressure is the blood pressure pumped from the left ventricle and measured at the root of the aorta. Systolic blood pressure is determined by the force and volume of blood that the left ventricle ejects. Central venous pressure reflects the blood pressure returning to the heart. 14
Which of the following nursing diagnosis is the nurse most correct to choose when caring for a client with long-standing hypertension? A) Impaired Gas Exchange B) Activity Intolerance C) Ineffective Tissue Perfusion D) Risk for Decreased Cardiac Output
C Feedback: The nurse is most correct in choosing ineffective tissue perfusion for the client with long-standing hypertension. In hypertension, the extra work increases the size of the heart muscle. Eventually, the heart cannot meet the body's metabolic needs limiting the perfusion to the tissues. Impaired Gas Exchange, Activity Intolerance, and a Risk for Decreased Cardiac Output may occur due to the ineffective perfusion. 34
The nurse is caring for a client with long-standing hypertension. As a client advocate, which instruction is most helpful in preventing further complications? A) Maintain a healthy diet of fruits and vegetables. B) Focus on exercise at least twice a week. C) Obtain a regular appointment with eye doctor. D) Avoid use of caffeinated beverages.
C Feedback: When a client has long-standing hypertension, the high blood pressure damages the arterial vascular system. As a client advocate, the nurse must instruct on not only prevention but also on early identification of complications. Damages may occur to the tiny arteries in the eyes compromising vision. The most helpful instruction is to maintain a regular appointment with an eye doctor. The other options are good instruction for a healthy lifestyle. 18
You are caring for a client diagnosed with secondary hypertension. What would be a predisposing condition for this diagnosis? A) Use of valium B) Hypoaldosteronism C) Pancreatic disease D) Use of oral contraceptives
D Feedback: Predisposing conditions include kidney disease, pheochromocytoma (a tumor of the adrenal medulla), hyperaldosteronism (increased secretion of mineralcorticoid by the adrenal cortex), atherosclerosis, use of cocaine or other cardiac stimulants (e.g., weight-control drugs, caffeine), and use of oral contraceptives. Secondary hypertension is not caused by the use of sedatives, hypoaldosteronism, or pancreatic disease. 11
Which ethnic background would the nurse screen for hypertension at an early age? A) Asian population B) Japanese population C) Mexican population D) African American population
D Feedback: The African American population is at the highest risk for development of hypertension. The other ethnic backgrounds have a lower risk. 32
You are caring for a client with hypertension who is experiencing complications. What diagnostic test evaluates the efficiency or inefficiency of the heart to pump blood? A) Echocardiography B) Chest radiography C) Computed tomography scan D) Multiple gated acquisition (MUGA) scan
D Feedback: The MUGA is a test that detects how efficiently or inefficiently the heart pumps blood. Echocardiography and chest radiography are used to reveal an enlarged left ventricle. The computed tomography scan is used to reveal abnormalities in blood pressure. 6
You are teaching a health class at the local YMCA. What body system would you explain regulates arterial blood pressure? A) Cardiovascular system B) Immune system C) Lymphatic system D) Autonomic nervous system
D Feedback: The autonomic nervous system, the kidneys, and various endocrine glands regulate arterial pressure. The cardiovascular system, immune system, and lymphatic systems do not regulate arterial blood pressure. 8
The nurse is caring for a client who is newly diagnosed with hypertension. The client states, "I do not understand what is causing my blood pressure to continue to rise." Which information does the nurse recognize as the key structure in regulating arterial blood pressure? A) Heart B) Lung C) Brain D) Kidney
D Feedback: The body regulates blood pressure throughout the day. The components of the autonomic nervous system, the kidneys, and endocrine glands regulate arterial pressure. The heart is the pump sending blood throughout the system. The lungs exchange oxygen but do not affect blood pressure. The brain recognizes and processes sympathetic nervous system activity to raise blood pressure. 13