A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms.
What response by the nurse is best?
"Do you have trouble affording your medications?"
"Most people with hypertension do not have symptoms.”.
"You are lucky; most people get severe morning headaches.”.
"You need to take your medicine or you will get kidney failure.”.
The Correct Answer is B
Choice A rationale
While medication cost can be a barrier to adherence, it doesn't directly address the client's misconception about the disease itself. Focusing on this aspect may be premature and might not resolve the client's core belief that treatment is unnecessary without symptoms.
Choice B rationale
This statement provides accurate and crucial scientific information. Hypertension is often called the "silent killer" because it typically has no symptoms until it causes significant end-organ damage. Explaining this concept directly addresses the client's flawed reasoning about medication adherence.
Choice C rationale
This response is dismissive and inaccurate. Most people with hypertension do not experience severe morning headaches, and this statement might mislead the client into thinking their lack of symptoms is a sign of good health, thereby reinforcing their decision not to take medication.
Choice D rationale
This response uses scare tactics, which can be counterproductive. While kidney failure is a potential consequence of untreated hypertension, a more educational and less confrontational approach is generally more effective for promoting long-term adherence to a medical regimen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
Choice A rationale
Regular assessment for bleeding is critical because heparin inhibits the coagulation cascade by enhancing antithrombin III, which inactivates thrombin and factor Xa. This increases the risk of hemorrhage, so the nurse must monitor for signs like petechiae, ecchymosis, hematuria, or GI bleeding to prevent serious complications. Platelets should be maintained above 100,000.
Choice B rationale
The activated partial thromboplastin time (aPTT) measures the time it takes for a fibrin clot to form via the intrinsic and common pathways of the coagulation cascade. Heparin therapy is monitored by the aPTT, with a therapeutic range typically 1.5 to 2.5 times the client’s baseline or control value, usually 45-75 seconds.
Choice C rationale
Stopping an IV heparin infusion for an aPTT above baseline is not always the correct action, as the therapeutic range is purposefully elevated. The aPTT should be 1.5 to 2.5 times the control value. An aPTT above this therapeutic range warrants holding the dose or adjusting the rate according to established hospital protocols and provider orders.
Choice D rationale
Using an IV pump is essential for heparin infusion to ensure precise and consistent administration. Heparin is a high-alert medication with a narrow therapeutic index. An IV pump prevents boluses and ensures the client receives the exact prescribed dose over time, minimizing the risk of subtherapeutic levels or overdose.
Choice E rationale
Daily weighing is crucial for monitoring fluid balance and detecting fluid shifts, which can indicate internal bleeding, a significant risk with heparin. Using the same scale at the same time each day, with the client wearing similar clothing, ensures accurate and comparable measurements, providing a reliable trend of the client’s weight.
Correct Answer is A
Explanation
Choice A rationale
Scabies is caused by the mite Sarcoptes scabiei, which burrows into the stratum corneum of the epidermis to lay eggs. This infestation triggers a hypersensitivity reaction (type IV) in the host, resulting in intense pruritus (itching) due to inflammatory mediators. The itching is often worse at night because mite activity increases with warmth, and the host's body temperature rises under bed covers. The characteristic burrows and vesicles are commonly found in interdigital spaces and the axilla.
Choice B rationale
Pediculosis capitis, or head lice, is an infestation caused by the head louse, Pediculus humanus capitis. This parasite feeds on human blood from the scalp, leading to intense itching (pruritus) primarily on the head. Itching is a result of an allergic reaction to the louse saliva. Unlike scabies, pediculosis does not typically present with a rash in the interdigital spaces or axilla, but rather nits (eggs) and lice on the hair shaft and scalp.
Choice C rationale
Tinea corporis, commonly known as ringworm, is a superficial fungal infection of the skin caused by dermatophytes. It presents as an erythematous, circular, scaling patch with a raised border and central clearing, giving it the characteristic ring-like appearance. While it can cause itching (pruritus), it is a localized infection and does not typically manifest with generalized, nocturnal pruritus in the axilla and between the fingers like scabies.
Choice D rationale
Eczema, or atopic dermatitis, is a chronic inflammatory skin condition characterized by dry, erythematous, pruritic patches. While it causes intense itching, which can be worse at night, the distribution and presentation are different from scabies. Eczema typically affects the flexural areas (e.g., antecubital and popliteal fossae) in adolescents, and does not involve the characteristic burrows or interdigital rash associated with a mite infestation.
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