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).
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
A respiratory rate of 22 breaths per minute is slightly elevated but not necessarily concerning for a client with COPD. COPD patients often have higher respiratory rates due to their chronic lung condition.
Choice B rationale
A temperature of 38°C (100.4°F) indicates a fever, which could be a sign of infection. However, it is not the most concerning finding in a COPD patient.
Choice C rationale
A pulse oximetry reading of 88% is concerning because it indicates hypoxemia. COPD patients often have lower oxygen levels, but a reading below 90% is worrisome and may require supplemental oxygen or other interventions.
Choice D rationale
A blood pressure of 140/90 mmHg is elevated but not immediately concerning in the context of COPD. It is important to monitor, but it is not the most critical finding.
Correct Answer is B
Explanation
Choice A rationale
Checking blood sugar levels before each meal is a good practice for managing diabetes and does not indicate a need for further teaching.
Choice B rationale
Skipping medication if blood sugar is normal indicates a misunderstanding of diabetes management. Medications should be taken as prescribed to maintain consistent blood sugar levels.
Choice C rationale
Following a balanced diet and exercising regularly are important components of diabetes management and do not indicate a need for further teaching.
Choice D rationale
Monitoring feet for cuts or sores is crucial for diabetes management to prevent complications like infections and ulcers.
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