A client with a history of hypertension is admitted with a severe headache and blurred vision. Which of the following findings would indicate a hypertensive crisis?

Blood pressure of 180/120 mmHg.

Heart rate of 90 beats per minute.

Respiratory rate of 20 breaths per minute.

Temperature of 37°C (98.6°F).

Answer and Explanation

The Correct Answer is A

Choice A rationale
A blood pressure reading of 180/120 mmHg or higher is indicative of a hypertensive crisis. This condition requires immediate medical attention to prevent damage to vital organs such as the heart, kidneys, and brain.
Choice B rationale
A heart rate of 90 beats per minute is within the normal range and does not indicate a hypertensive crisis. While it is important to monitor heart rate, it is not a definitive sign of a hypertensive emergency.
Choice C rationale
A respiratory rate of 20 breaths per minute is within the normal range and does not indicate a hypertensive crisis. Respiratory rate alone is not a reliable indicator of hypertensive emergencies.
Choice D rationale
A temperature of 37°C (98.6°F) is normal and does not indicate a hypertensive crisis. Body temperature is not a primary indicator of hypertensive emergencies.

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Correct Answer is A

Explanation

Choice A rationale
A temperature of 38°C (100.4°F) and a stiff neck are classic signs of meningitis, indicating inflammation of the meninges.
Choice B rationale
Myocardial infarction typically presents with chest pain, not a stiff neck.
Choice C rationale
Appendicitis presents with abdominal pain, not a stiff neck.
Choice D rationale
Pneumonia presents with respiratory symptoms, not a stiff neck.

A. Administering supplemental oxygen. B. Encouraging the client to use an incentive spirometer. C. Administering a bronchodilator as prescribed. D. Positioning the client in high Fowler’s position.

Correct Answer is A

Explanation

Choice A rationale
Administering supplemental oxygen is the priority intervention for a client with COPD who has an oxygen saturation of 88% on room air. This low oxygen saturation indicates hypoxemia, which requires immediate correction to prevent further respiratory distress.
Choice B rationale
Encouraging the client to use an incentive spirometer is important for lung expansion and preventing atelectasis, but it is not the priority intervention in this scenario. The immediate concern is to correct the hypoxemia.
Choice C rationale
Administering a bronchodilator as prescribed is important for managing COPD symptoms, but the priority intervention is to correct the hypoxemia by administering supplemental oxygen.
Choice D rationale
Positioning the client in high Fowler’s position can help improve breathing, but the priority intervention is to correct the hypoxemia by administering supplemental oxygen.

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A client with a history of hypertension is admitted with a severe headache and blurred vision. Which of the following findings would indicate a hypertensive crisis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client presents with a temperature of 38°C (100.4°F) and a stiff neck. Which condition should the nurse suspect?

Correct Answer is A

Explanation

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with increased shortness of breath and a productive cough. The nurse notes the client’s oxygen saturation is 88% on room air. Which of the following interventions should the nurse implement first?

Correct Answer is A

Explanation

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