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 C
Explanation
Choice A rationale:
Purpura refers to purple or red discolorations on the skin caused by bleeding underneath the skin. It is larger than petechiae and ecchymosis and could be a sign of a more serious underlying condition. Petechiae are small, red or purple dots that appear on the skin due to minor bleeding from broken capillaries. In the context of leukemia and thrombocytopenia (low platelet count), petechiae are common due to impaired clotting mechanisms.
Choice B rationale:
Bruising occurs due to damage to blood vessels underneath the skin, resulting in the leakage of blood into the surrounding tissues. Bruises are typically larger than petechiae and can occur with various conditions, including trauma. In this case, the small 1-mm red macules are more indicative of petechiae.
Choice D rationale:
Ecchymosis refers to a larger area of subcutaneous bleeding or bruising. It is larger than both petechiae and purpura and often results from more significant trauma or bleeding disorders. The description of multiple 1-mm red macules is characteristic of petechiae rather than ecchymosis.
Correct Answer is D
Explanation
Choice A rationale:
Adequate platelet production does not explain the prolonged bleeding times in von Willebrand disease. These patients often have normal platelet counts, but their platelets do not function properly due to the absence or dysfunction of von Willebrand factor.
Choice B rationale:
Deficiency in intrinsic clotting system factor is not the primary cause of prolonged bleeding times in von Willebrand disease. The deficiency or dysfunction of von Willebrand factor, a protein that helps platelets adhere to the blood vessel walls and clot properly, is the key issue in this disorder.
Choice C rationale:
Impairment of the thrombin fibrinogen reaction does not directly relate to von Willebrand disease. This disorder primarily involves platelet dysfunction and variable factor VIII deficiencies, leading to prolonged bleeding times.
Choice D rationale:
Variable factor VIII deficiencies and platelet dysfunction are characteristic of von Willebrand disease. Factor VIII helps with blood clotting, and its deficiency, along with impaired platelet function, contributes to the prolonged bleeding times in patients with von Willebrand disease.
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