A client with a history of hypertension treated with a diuretic and an angiotensin-converting enzyme (ACE) inhibitor arrives in the emergency department. The client reports a severe headache and nausea and has a blood pressure (BP) of 238/118 mm Hg. Which question should the nurse ask to follow up on these findings?

"Have you recently taken any antihistamines?"

"Have there been recent stressful events in your life?"

"Have you consistently taken your medications?"

"Did you take any acetaminophen/Tylenol) today?"

Answer and Explanation

The Correct Answer is B

The client presenting to the emergency department with a severe headache, nausea, and significantly elevated blood pressure (BP) of 238/118 mm Hg indicates a hypertensive crisis, which is a severe and potentially life-threatening condition. In such cases, the nurse's priority is to assess for potential triggers or exacerbating factors for the hypertensive crisis.

Option B, "Have there been recent stressful events in your life?" is the most relevant question to follow up on the findings. Stress is a known trigger for acute elevations in blood pressure, and severe stress can lead to a hypertensive crisis in individuals with a history of hypertension. Identifying recent stressful events may help the nurse understand potential contributing factors to the client's current condition and guide the management plan.

Option A, "Have you recently taken any antihistamines?" is not the most relevant question in this situation. Antihistamines are not typically associated with causing a hypertensive crisis. While certain medications and substances can interact with antihypertensive medications, causing an increase in BP, the severity of the client's symptoms and the extremely high BP reading suggest that a more immediate concern needs to be addressed.

Option C, "Have you consistently taken your medications?" is important for assessing medication adherence, but it may not directly explain the acute hypertensive crisis. The client's current symptoms and BP reading require more immediate investigation into potential triggers.

Option D, "Did you take any aspirin (or Tylenol) today?" is relevant to assess whether the client has recently taken any over-the-counter medications that could potentially interact with their prescribed antihypertensive drugs. However, it is not the most critical question to address the hypertensive crisis and the severity of the client's symptoms.

Given the severity of the client's presentation, the nurse should also promptly initiate appropriate interventions to address the hypertensive crisis, such as administering antihypertensive medications as prescribed, monitoring vital signs frequently, and notifying the healthcare provider for further evaluation and management.

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Correct Answer is C

Explanation

Among the given options, the most important information for the nurse to include when teaching a client newly diagnosed with hypertension is option C, "Increasing physical activity controls blood pressure (BP) for most people."

Option C emphasizes the importance of increasing physical activity as a primary lifestyle modification to control blood pressure for most people with hypertension. Regular physical activity can help improve cardiovascular health, reduce blood pressure, and manage overall health. It is a proactive step that the individual can take immediately to start managing their hypertension.

Incorrect:

Option A, "Most people are able to control BP through dietary changes," is not necessarily true for everyone. While dietary changes, such as reducing sodium intake and adopting a heart-healthy diet, can be beneficial in managing hypertension, they may not be sufficient for everyone. Physical activity is an essential component of hypertension management and has broader health benefits.

Option B, "Annual BP checks are needed to monitor treatment effectiveness," is important information, but it is more of a recommendation for ongoing hypertension management rather than the most critical information for someone newly diagnosed with hypertension. Regular blood pressure monitoring is indeed crucial for treatment assessment and ensuring that the chosen treatment plan is effective.

Option D, "Hypertension is usually asymptomatic until target organ damage occurs," is important information to understand the nature of hypertension, but it does not provide immediate guidance for the newly diagnosed individual on how to manage their condition effectively.

As part of a comprehensive hypertension education plan, the nurse can provide additional information about dietary changes, regular blood pressure monitoring, and the importance of early management to prevent target organ damage. However, emphasizing physical activity as a fundamental aspect of hypertension management is the most important initial step for a newly diagnosed client. The nurse can then tailor the education based on the individual's specific needs and health status.

A. Delegated to the health care provider B. Discussed along with other physical activities C. Avoided because it is embarrassing to the patient D. Accomplished by providing the patient with written material

Correct Answer is B

Explanation

Resumption of sexual activity after a myocardial infarction (MI) is an important topic to address as part of the overall recovery and rehabilitation process. It should be discussed along with other physical activities during the patient's recovery. The nurse should initiate the discussion in a supportive and non-judgmental manner, addressing the patient's concerns, fears, and questions about sexual activity after an MI.

Sexual activity is a normal part of life, and patients may have concerns about the safety and appropriateness of engaging in sexual activity after a significant cardiac event like an MI. Discussing it along with other physical activities helps normalize the topic and allows the nurse to provide accurate information, address any misconceptions, and offer guidance on when and how to resume sexual activity safely. Patients should be encouraged to have an open dialogue with their healthcare provider about their concerns and any specific questions they may have related to resuming sexual activity.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which information is most important for the nurse to include when teaching a client newly diagnosed with hypertension?

Correct Answer is C

Explanation

The nurse is providing teaching to a patient recovering from a myocardial infarction (MI). How should resumption of sexual activity be discussed?

Correct Answer is B

Explanation

Which topic will the nurse plan to include in discharge teaching for a client who has heart failure with reduced ejection fraction?

During the 48 hours after a myocardial infarction (MI), a nurse should assign the highest priority to monitoring the patient for what complication?

Which assessment finding of a patient with chronic kidney disease indicates to the nurse that hemodialysis is having the desired effect?

Which electrocardiographic (ECG) change by a client with chest pain is most important for the nurse to report rapidly to the health care provider?

A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?

A patient with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. What topic should the nurse plan to include in patient teaching?

A nurse is providing dietary teaching to a client who has chronic kidney disease (CKD). The nurse should instruct the client to limit which of the following nutrients? (Select all that apply.)