A nurse is assessing a client with a history of hypertension who presents with a severe headache, blurred vision, and confusion.

The nurse should prioritize which of the following actions?

Administering antihypertensive medication as prescribed.

Preparing the client for a lumbar puncture.

Initiating seizure precautions.

Monitoring the client’s blood glucose levels.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Administering antihypertensive medication as prescribed is the priority action for a client with a history of hypertension presenting with severe headache, blurred vision, and confusion.
These symptoms suggest a hypertensive crisis, which requires immediate blood pressure reduction to prevent further complications.
Choice B rationale
Preparing the client for a lumbar puncture is not the priority action in this scenario. While a lumbar puncture may be necessary to rule out other conditions, the immediate concern is to manage the hypertensive crisis.
Choice C rationale
Initiating seizure precautions is important if the client is at risk of seizures, but the priority action is to address the hypertensive crisis by administering antihypertensive medication.
Choice D rationale
Monitoring the client’s blood glucose levels is important for overall health management, but it is not the priority action in this scenario. The immediate concern is to manage the hypertensive crisis.

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Correct Answer is B

Explanation

Choice A rationale
Hypercalcemia is characterized by increased calcium levels in the blood, often due to increased absorption of calcium from the gut. However, in chronic kidney disease (CKD), the kidneys’ ability to activate vitamin D is impaired, leading to decreased calcium absorption from the gut, not increased. Therefore, hypercalcemia is not a typical sign of CKD1.
Choice B rationale
A positive Chvostek’s sign is indicative of hypocalcemia, which is a common symptom in CKD. The kidneys’ reduced ability to activate vitamin D leads to decreased calcium absorption from the gut, resulting in low calcium levels in the blood. This hypocalcemia can cause neuromuscular irritability, leading to a positive Chvostek’s sign.
Choice C rationale
Tetany is a condition characterized by muscle cramps and spasms, often due to hypocalcemia. In CKD, hypocalcemia occurs due to the kidneys’ inability to activate vitamin D, leading to decreased calcium absorption from the gut. This hypocalcemia can cause hyperexcitability of nerves and muscles, resulting in tetany.
Choice D rationale
Hyperphosphatemia is characterized by high phosphate levels in the blood. In CKD, the kidneys’ ability to excrete phosphate is impaired, leading to its accumulation in the blood. However, this is not directly related to the inability to absorb phosphate from the gut but rather the kidneys’ reduced excretion capacity.

A. The patient who has hyperkalemia and is weak and tired. B. The patient who sometimes experiences chest pain when climbing a flight of stairs. C. The patient who is experiencing persistent and severe chest pain when at rest. D. The patient who has paroxysmal nocturnal dyspnea (PND).

Correct Answer is C

Explanation

Choice A rationale
Hyperkalemia can cause weakness and fatigue, but it is not directly related to acute coronary syndrome (ACS). ACS is primarily associated with chest pain and other cardiac symptoms.
Choice B rationale
Experiencing chest pain when climbing a flight of stairs may indicate stable angina, which is a form of chronic coronary artery disease. However, it does not meet the criteria for ACS, which involves more severe and persistent symptoms.
Choice C rationale
Persistent and severe chest pain when at rest is a hallmark symptom of acute coronary syndrome (ACS). This condition requires immediate medical attention as it can lead to myocardial infarction (heart attack) or other serious complications.
Choice D rationale
Paroxysmal nocturnal dyspnea (PND) is a symptom of heart failure, not acute coronary syndrome (ACS). While heart failure can coexist with ACS, PND alone does not indicate ACS4.

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A nurse is assessing a client with a history of hypertension who presents with a severe headache, blurred vision, and confusion. The nurse should prioritize which of the following actions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with chronic kidney disease usually has a decrease in the ability to activate vitamin D, likely resulting in signs and symptoms (S&S) such as:

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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A nurse is assessing a client with a history of hypertension who presents with a severe headache, blurred vision, and confusion.

The nurse should prioritize which of the following actions?