A patient with a history of hypertension arrives in the emergency department with a blood pressure (BP) reading of 213/126 mm Hg. The patient has a history of drug abuse.

Which of the following initial questions posed by the nurse is MOST appropriate?.

"Did you take any Tylenol today?".

"Have there been recent stressful events in your life?".

"Have you recently taken any cocaine or crack?".

"Have you eaten any salty foods lately?". .

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Tylenol, or acetaminophen, is a common over-the-counter medication used to reduce fevers and manage mild aches and pains. It does not directly affect blood pressure.

Choice B rationale:

While stress can cause temporary spikes in blood pressure, it’s not clear whether stress can cause long-term increases in blood pressure34.

Choice C rationale:

Cocaine or crack use can cause a significant and dangerous increase in blood pressure. Given the patient’s history of drug abuse and the current high blood pressure reading, this is a critical question to ask.

Choice D rationale:

Eating salty foods can contribute to high blood pressure over time, but it’s unlikely to cause an immediate severe increase in blood pressure.

So, the correct answer is Choice C, after analyzing all choices. .

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Correct Answer is ["A","B","C"]

Explanation

Choice A rationale:

Obtaining blood cultures x 3 is anticipated for the client. This is because the adolescent’s symptoms such as fever, shortness of breath, and petechiae could indicate a bacterial infection, possibly endocarditis, which is a risk for individuals with a history of rheumatic fever and cardiac valve damage. Blood cultures would help identify the causative bacteria.

Choice B rationale:

Administering antibiotic therapy is anticipated for the client. The adolescent’s symptoms suggest a possible bacterial infection, which could have been introduced during the recent dental work. Antibiotics would help eliminate the bacteria and prevent further complications.

Choice C rationale:

Obtaining an echocardiogram is anticipated for the client. Given the adolescent’s history of rheumatic fever and cardiac valve damage, and current symptoms like shortness of breath and chest pain, an echocardiogram would help assess the condition of the heart valves and detect any abnormalities.

Choice D rationale:

Restricting dental hygiene is contraindicated for the client. Good oral hygiene is important, especially for individuals with a history of rheumatic fever and cardiac valve damage, as it helps prevent oral infections that could potentially spread to the heart.

Choice E rationale:

Performing a strenuous exercise regimen twice daily is contraindicated for the client. The adolescent is currently experiencing symptoms like shortness of breath and chest pain, which could be exacerbated by strenuous exercise. It’s important to avoid overexertion until the adolescent’s condition stabilizes.

So, the correct answer is, after analyzing all choices, Choices A, B, and C are anticipated for the client, while Choices D and E are contraindicated. .

A. Patient with dilated cardiomyopathy who has bilateral crackles at the lung bases. B. Patient with acute aortic regurgitation whose blood pressure is 86/54 mm Hg. C. Patient with infective endocarditis who has a murmur and splinter hemorrhages. D. Patient with rheumatic fever who has sharp chest pain with a deep breath.

Correct Answer is B

Explanation

Choice A rationale:

While bilateral crackles at the lung bases indicate fluid accumulation, a common symptom of dilated cardiomyopathy, it’s not as immediately life-threatening as some other conditions.

Choice B rationale:

Acute aortic regurgitation can lead to a rapid and severe drop in blood pressure, which is a medical emergency. Therefore, this patient should be assessed first.

Choice C rationale:

While a murmur and splinter hemorrhages are symptoms of infective endocarditis, they are not as immediately life-threatening as acute aortic regurgitation.

Choice D rationale:

Sharp chest pain with a deep breath could be a symptom of rheumatic fever, but it’s not as immediately life-threatening as acute aortic regurgitation.

So, the correct answer is Choice B, after analyzing all choices.

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A patient with a history of hypertension arrives in the emergency department with a blood pressure (BP) reading of 213/126 mm Hg. The patient has a history of drug abuse. Which of the following initial questions posed by the nurse is MOST appropriate?.

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C"]

Explanation

After receiving a change-of-shift report on four patients, which patient would the nurse assess first?.

Correct Answer is B

Explanation

A patient with a history of hypertension arrives in the emergency department with a blood pressure (BP) reading of 213/126 mm Hg. The patient has a history of drug abuse. Which of the following initial questions posed by the nurse is MOST appropriate?.

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A patient with a history of hypertension arrives in the emergency department with a blood pressure (BP) reading of 213/126 mm Hg. The patient has a history of drug abuse.

Which of the following initial questions posed by the nurse is MOST appropriate?.