A female patient with chronic hypertension is admitted to the emergency department with a sudden rise in blood pressure (BP) Which question is the priority for the nurse to ask the patient?
"Are you pregnant?”
"Do you need to urinate?”
"Do you have a headache or confusion?”
"Are you taking antiseizure medications?”
The Correct Answer is C
Choice A rationale:
While pregnancy can contribute to increased blood pressure, it is not the priority question in this scenario. The sudden rise in blood pressure could indicate a hypertensive crisis, which needs immediate attention.
Choice B rationale:
Urination is not directly related to sudden rises in blood pressure. While urinary issues could be a sign of certain conditions, they are not the priority when dealing with a hypertensive emergency.
Choice C rationale:
A sudden rise in blood pressure can lead to symptoms such as headache and confusion, which could indicate a hypertensive crisis. This question is crucial to assess neurological symptoms, which can be indicative of target organ damage due to hypertension.
Choice D rationale:
Antiseizure medications are not directly related to sudden increases in blood pressure. Neurological symptoms (like those in choice C) are more indicative of a hypertensive crisis and require immediate attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
Choice A rationale:
Eliminating excess H+ ions (hydrogen ions) is a primary mechanism the kidneys use to buffer acidosis. In acidosis, there is an excess of hydrogen ions in the body, leading to a decrease in pH. The kidneys help regulate the body's pH by excreting hydrogen ions to lower acidity.
Choice B rationale:
Excreting excess water is not a specific acid-base mechanism related to acidosis. While maintaining proper hydration is important for overall health, it does not directly influence the body's acid-base balance in the context of acidosis.
Choice C rationale:
Eliminating excess CO2 is primarily a respiratory mechanism, not a kidney function. CO2 elimination is more related to the lungs' ability to regulate the body's pH by adjusting respiratory rate and depth.
Choice D rationale:
Reabsorbing additional HCO3- ions (bicarbonate ions) is a renal mechanism to buffer acidosis. Bicarbonate ions act as a base and can neutralize excess hydrogen ions, raising the pH of the body fluids.
Choice E rationale:
Reabsorbing additional sodium ions is not a specific acid-base mechanism related to acidosis. While sodium ions are important for various physiological processes, they do not play a direct role in buffering acidosis.
Correct Answer is C
Explanation
Choice A rationale:
Spasm of a major coronary artery, also known as variant (Prinzmetal's) angina, typically occurs at rest and is not necessarily provoked by exertion. The patient's chest pain is exacerbated by exertion, making this choice less likely.
Choice B rationale:
Exposure of the thrombogenic surface to plaque refers to acute coronary syndromes like unstable angina or myocardial infarction. While plaque rupture and thrombosis can cause myocardial ischemia, the characteristic feature of these conditions is chest pain that may not be relieved by rest, unlike the patient described here.
Choice D rationale:
Myocardial ischemia secondary to microvascular disease, also known as cardiac syndrome X, is a condition where chest pain occurs without significant coronary artery stenosis. However, this condition usually affects women, and the pain is often unrelated to exertion. In the given case, the pain is provoked by exertion, making this choice less likely.
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