A nurse in the emergency department is caring for a client who is experiencing chest pain. Physical Examination

0900:

Client admitted with a report of chest pain radiating to the left arm, sweating, shortness of breath, and epigastric discomfort

Client awake, alert, and oriented x3.

Lung sounds clear bilaterally, S1S2 heart sounds noted.

All pulses palpable.

Skin cool and diaphoretic to touch.

Rates pain as 6 on a 0 to 10 pain scale.

tachycardia with ST elevation. Provider notified.

Medication Administration Record:

Sildenafil 50 mg PO once daily

Simvastatin 40 mg PO once daily

Metoprolol 100 mg PO once daily

Multivitamin once daily

The nurse is reviewing the client's assessment data to prepare the plan of care. What is the potential condition for this client? Select one (1) answer.

The most important finding to report to the healthcare provider in a client admitted to the intensive care unit (ICU) with a hypertensive emergency is option B, "The client cannot move the left arm and leg when asked to do so."

Hypertensive emergencies are critical situations where extremely high blood pressure levels can lead to damage or dysfunction in vital organs, such as the brain, heart, kidneys, and eyes. Neurological symptoms are particularly concerning in this context, as they may indicate acute brain injury or stroke resulting from uncontrolled high blood pressure.

Option A, "Tremors are noted in the fingers when the client extends the arms," could be concerning but is not as immediately critical as the neurological deficit described in option B. Tremors can have various causes and may not directly relate to the hypertensive emergency unless other signs or symptoms of neurologic impairment are also present.

Option C, "Urine output over 8 hours is 250 mL less than the fluid intake," is relevant to monitor the client's fluid status and kidney function, but it does not indicate an acute, life-threatening condition that requires immediate attention like the neurological deficit in option B.

Option D, "The client reports a headache with pain at level 7 of 10 (0 to 10 scale)," is concerning and may be a symptom of the hypertensive emergency, but it is not as urgent as the neurological findings. Headache can be a symptom of elevated blood pressure, but it is not sufficient on its own to determine the severity of the hypertensive crisis.

In a hypertensive emergency, the priority is to identify and manage potential complications, such as neurological deficits, acute organ damage, or signs of target organ dysfunction. Prompt reporting of any neurological changes is crucial, as it may prompt immediate interventions to prevent further neurological deterioration. The healthcare provider needs to assess the client's neurological status promptly and determine appropriate management to prevent further complications.

The assessment findings of jugular venous distention, weight gain, peripheral edema, and a heart rate of 108/minute are consistent with right-sided heart failure (HF). Right-sided HF occurs when the right ventricle of the heart is unable to pump effectively, leading to congestion in the venous circulation. This can result in jugular venous distention (JVD) due to increased pressure in the jugular veins, peripheral edema due to fluid retention, and weight gain due to fluid accumulation.

Option A (Left-sided HF) may also present with similar symptoms like jugular venous distention, weight gain, and peripheral edema. However, in left-sided HF, there would typically be signs of pulmonary congestion, such as crackles in the lungs and shortness of breath.

Option C (Chronic heart failure) is a general term used for heart failure that has been present for an extended period, and it does not specify whether it is left-sided or right-sided heart failure.

Option D (Acute decompensated heart failure - ADHF) is a form of heart failure that presents with severe symptoms and requires urgent treatment. It is more of a clinical classification rather than a specific complication related to the symptoms mentioned in the scenario.