A nurse is assessing a client who is experiencing a hypertensive crisis. Which of the following manifestations should the nurse expect?
Skin cool to touch
Jugular vein distention
Headache
Weak peripheral pulses
The Correct Answer is C
Rationale:
A. Skin cool to touch: Cool skin is more commonly associated with shock states or severe peripheral vasoconstriction, not with a hypertensive crisis. In hypertensive crisis, the client is more likely to have warm skin due to increased circulation from elevated blood pressure.
B. Jugular vein distention: While jugular vein distention can occur in right-sided heart failure or severe fluid overload, it is not a hallmark manifestation of hypertensive crisis. The acute issue in hypertensive crisis is extreme elevation in blood pressure with end-organ effects.
C. Headache: Severe headache is a common and classic symptom of hypertensive crisis due to sudden, extreme elevations in blood pressure causing increased ICP and cerebral vessel stress. It often signals an urgent need for BP control to prevent complications such as stroke.
D. Weak peripheral pulses: Weak pulses are more often associated with low cardiac output or severe arterial obstruction. In hypertensive crisis, peripheral pulses are typically bounding and strong because of the elevated systemic vascular resistance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "A living will is a document that includes my wishes about health care decisions.": A living will is an advance directive that specifies a client’s preferences for medical treatment in situations where they are unable to communicate.
B. "My partner needs to be present as a witness when I sign a living will.": Witness requirements vary by state, and typically a neutral adult, not necessarily a partner, must witness the signing.
C. "My provider will make my health care decisions if I complete advance directives.": Advance directives are intended to communicate the client’s own wishes, not delegate decision-making solely to the provider. The provider’s role is to follow the client’s documented preferences.
D. "Advance directives outline who inherits my material possessions in the event of my death.": Inheritance is addressed in a will, not advance directives. Advance directives focus exclusively on medical and end-of-life care decisions.
Correct Answer is D
Explanation
Rationale:
A. A colleague who uses assertive communication: Assertive communication is a positive professional skill that promotes clarity and mutual respect. It involves expressing needs and opinions confidently while respecting the rights of others, not bullying behavior.
B. A colleague who is mindful of the personal space of other colleagues: Respecting personal space reflects professional courtesy and helps maintain a comfortable work environment. It does not represent any form of bullying or intimidation.
C. A colleague who negotiates with others for a win-win situation: Negotiation aimed at mutual benefit demonstrates collaboration and problem-solving, which are constructive workplace behaviors, not bullying tactics.
D. A colleague who finds fault with other colleagues: Habitually criticizing or fault-finding without constructive intent is a form of workplace bullying. This behavior undermines morale, creates a hostile environment, and can damage professional relationships.
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