Client Data

Exhibits

The LPN/LVN determines that the patient is in hypertensive urgency crisis and that his blood pressure will need to be lowered slowly. The nurse is also concerned that the blood pressure is elevated while the patient is on antihypertensives. Which additional information would be most important for the nurse to collect from the patient?

Has the patient been taking his medications as prescribed?

Does the patient hurt anywhere else?

When does the patient take his furosemide?

Has the patient fallen before?

Answer and Explanation

The Correct Answer is D

Has the patient been taking his medications as prescribed? This is the most important information to collect. Understanding the patient's medication adherence is crucial because if the patient is not taking his medications as prescribed, it could explain why his blood pressure is elevated. Noncompliance with medication regimens is a common cause of hypertensive urgency and can lead to severe complications. Therefore, knowing whether he has been taking his medications regularly and correctly would directly influence the management plan and help identify the cause of the current crisis.

Does the patient hurt anywhere else? While it’s important to assess for pain and discomfort to address immediate symptoms, this information does not directly address the potential cause of the elevated blood pressure. The patient already reported pain in the head, chest, and left leg, so the primary concern is managing his hypertensive urgency and understanding its underlying causes rather than identifying additional pain locations at this moment.

When does the patient take his furosemide? Knowing the timing of furosemide intake could provide insights into his diuretic therapy management and its potential impact on his blood pressure. However, it is less immediately relevant than understanding whether he has been taking all his medications as prescribed. This question might be more pertinent once medication adherence is confirmed to understand diuretic effects throughout the day.

Has the patient fallen before? This is relevant for assessing the risk of recurrent falls and potential underlying issues such as orthostatic hypotension or balance problems, which are crucial for long-term management and safety. However, it is not as immediately critical in the context of the current hypertensive urgency and the elevated blood pressure despite medication.

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Correct Answer is B

Explanation

A. Impaired Physical Mobility: This is not directly related to hypertension management. While hypertension can affect physical activity, it is not the primary focus in the context of managing high blood pressure.
B. Readiness for Enhanced Health Literacy: This is the correct focus. Educating the patient about hypertension management, lifestyle modifications, and medication adherence is crucial in managing and controlling blood pressure.
C. Decreased Activity Tolerance: This could be a related issue but is not the primary focus. It addresses the impact of hypertension on physical capacity rather than managing the condition itself.
D. Ineffective Airway Clearance: This is unrelated to hypertension. It focuses on respiratory issues rather than blood pressure management.

A. Monitoring for infection B. Monitoring circulatory status C. Validating proper mobility D. Checking discomfort level

Correct Answer is A

Explanation

Correct answer: A
A. Monitoring for infection: Infection is a significant risk with external fixation devices due to the presence of pins that penetrate the skin and soft tissues. Monitoring for signs of infection, such as redness, swelling, discharge, or increased pain, is crucial.
B. Monitoring circulatory status: While circulatory status is important, especially in cases of limb injury or immobilization, it is not the most immediate concern compared to the risk of infection from the external fixation device.
C. Validating proper mobility: Ensuring proper mobility is important, but it is secondary to the prevention and detection of infection. Mobility assessments can be done after confirming that there are no infections or complications.
D. Checking discomfort level: While assessing discomfort is important for pain management and comfort, it is not as critical as monitoring for infection, which can lead to severe complications if not addressed promptly.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse contributes to the plan of care for a patient with hypertension. Which of the following nursing diagnoses is the focus of care for the patient with hypertension?

Correct Answer is B

Explanation

The nurse is preparing for a home visit to a patient with an external fixation device of the lower extremity. What priority care is anticipated?

Correct Answer is A

Explanation

The nurse is caring for a patient with a fracture. Which complications should the nurse monitor for? Select all that apply.

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Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?

A patient comes into the emergency department with symptoms of a stroke that began 2 hours ago. Diagnostic testing confirms an ischemic stroke is present. What medications should the nurse anticipate will be delivered?

The nurse is reinforcing teaching about dietary changes with a patient newly diagnosed with hypertension. What should the nurse include in the teaching about a DASH diet? Select all that apply. (Select All that Apply.)