A client is admitted with a BP of 210/120 mmHg and severe headache. What is the nurse's priority action?
Place the client in Trendelenburg position
Encourage the client to ambulate
Administer prescribed antihypertensive IV
Provide a high-sodium det
The Correct Answer is C
A. Place the client in Trendelenburg position: Trendelenburg (head-down) position can increase intracranial pressure and worsen cardiovascular strain. It is contraindicated in hypertensive emergencies and is not an appropriate intervention for acute severe hypertension.
B. Encourage the client to ambulate: Physical activity can exacerbate elevated blood pressure and increase the risk of complications such as stroke or myocardial infarction. Bed rest or minimal activity is recommended until blood pressure is controlled.
C. Administer prescribed antihypertensive IV: A BP of 210/120 mmHg with severe headache indicates a hypertensive emergency requiring immediate intervention. Administering IV antihypertensives as prescribed allows rapid, controlled reduction of blood pressure to prevent end-organ damage, making this the priority action.
D. Provide a high-sodium diet: High sodium intake would worsen hypertension and is contraindicated in hypertensive emergencies. Dietary modifications are long-term interventions and not appropriate as an acute management strategy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Peptic ulcer disease: PUD primarily presents with epigastric pain, dyspepsia, and sometimes gastrointestinal bleeding. It does not explain heart murmurs, nail abnormalities, or hematuria, making it unlikely in this scenario.
B. Pulmonary embolism: PE typically presents with sudden shortness of breath, chest pain, tachypnea, and sometimes hemoptysis. A heart murmur and nail changes are not characteristic of PE, so this is less likely.
C. Endocarditis: Infective endocarditis often presents with fever, tachycardia, heart murmur, hematuria, myalgias, and nail findings such as splinter hemorrhages. The combination of these systemic and cardiovascular findings strongly suggests endocarditis.
D. Heart failure: Heart failure manifests with dyspnea, edema, fatigue, and sometimes pulmonary congestion. Fever, hematuria, and nail abnormalities are not typical, making it less likely as the primary diagnosis in this case.
Correct Answer is B
Explanation
A. Osteoporosis: Osteoporosis affects bone density and does not directly impact urinary tract function or susceptibility to infection. It is not considered a risk factor for developing a UTI.
B. Diabetes mellitus: Diabetes can impair immune function and lead to glycosuria, creating an environment that promotes bacterial growth in the urinary tract. Hyperglycemia and poor glycemic control increase the risk of both uncomplicated and complicated UTIs.
C. COPD: Chronic obstructive pulmonary disease primarily affects the respiratory system and does not directly increase UTI risk. Respiratory disease is not a recognized predisposing factor for urinary tract infections.
D. Anemia: Anemia reflects decreased red blood cell levels or hemoglobin but does not inherently alter susceptibility to urinary tract infections. While it may indicate overall health status, it is not a specific UTI risk factor.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.