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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice D. Then start with Choice A rationale:
Choice A is incorrect because it representsmetabolic alkalosis, not respiratory alkalosis. Metabolic alkalosis occurs when there is a primary increase in the bicarbonate (HCO3) level, which causes the pH to rise above the normal range (7.35-7.45). The PaCO2 is normal in this case, indicating that the respiratory system is not involved in the acid-base imbalance.Some causes of metabolic alkalosis include vomiting, diuretic use, excessive antacid intake, and mineralocorticoid excess1.
Choice B is incorrect because it representsrespiratory acidosis, not respiratory alkalosis. Respiratory acidosis occurs when there is a primary decrease in the PaCO2 level, which causes the pH to fall below the normal range. The HCO3 is normal in this case, indicating that the metabolic system is not involved in the acid-base imbalance.Some causes of respiratory acidosis include hypoventilation, airway obstruction, chest trauma, neuromuscular disorders, and chronic lung diseases2.
Choice C is incorrect because it representsmetabolic acidosis, not respiratory alkalosis. Metabolic acidosis occurs when there is a primary decrease in the HCO3 level, which causes the pH to fall below the normal range. The PaCO2 is normal in this case, indicating that the respiratory system is not involved in the acid-base imbalance.Some causes of metabolic acidosis include diabetic ketoacidosis, lactic acidosis, renal failure, diarrhea, and poisoning3.
Choice D is correct because it representsrespiratory alkalosis. Respiratory alkalosis occurs when there is a primary decrease in the PaCO2 level, which causes the pH to rise above the normal range. The HCO3 is normal in this case, indicating that the metabolic system is not involved in the acid-base imbalance. Some causes of respiratory alkalosis include hyperventilation, anxiety, panic, fever, pain, tumor, trauma, severe anemia, liver disease, overdose of certain medicines, pulmonary embolism, pregnancy, and any lung disease that leads to shortness of breath . Respiratory alkalosis is characterized by symptoms such as breathlessness, dizziness, numbness, tingling, muscle spasms, chest discomfort, confusion, and fainting.
Correct Answer is B
Explanation
Choice A rationale:
Flossing using thick tape floss can cause trauma to the gums and may lead to bleeding in patients with thrombocytopenia. Patients with low platelet counts are at risk of excessive bleeding from minor injuries, and using thick tape floss could potentially harm the gums and exacerbate bleeding.
Choice B rationale:
Shaving using an electric razor is a safe option for patients with thrombocytopenia. Electric razors do not pose a significant risk of cuts or nicks, reducing the likelihood of bleeding, which is crucial for patients with low platelet counts.
Choice C rationale:
Wearing flip-flops to go walking may not be the safest option for a patient with thrombocytopenia. If the patient accidentally stubs their toe or injures their foot while wearing flip-flops, it could lead to bleeding. Closed-toe, comfortable shoes provide better protection against foot injuries.
Choice D rationale:
Brushing using a stiff-bristle toothbrush can be harmful to the gums, especially for patients with thrombocytopenia. Stiff-bristle toothbrushes can cause gum irritation and bleeding. Patients with low platelet counts should use a soft-bristle toothbrush to minimize the risk of gum injury.
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