The nurse is assessing a client with a hypertensive emergency. Which ﬁnding is most important to report to the health care provider?

The client reports a headache with pain at level 5 of 10

The client has epistaxis after blowing his nose several times

The client has a urine output of 120 mL over a 4 hours

The client has a new-onset blurry vision and facial asymmetry

Answer and Explanation

The Correct Answer is D

The client reports a headache with pain at level 5 of 10.: While a headache can be a symptom of high blood pressure, a pain level of 5 out of 10 alone does not indicate an immediate life-threatening condition. It is important to assess and manage the client's pain, but it may not be the most critical ﬁnding to report in this situation.

The client has epistaxis after blowing his nose several times. : Epistaxis, or a nosebleed, can occur due to high blood pressure, but it is not the most urgent or critical symptom in a hypertensive emergency. While it is essential to address the nosebleed and monitor blood pressure, other symptoms may indicate more severe consequences of uncontrolled high blood pressure.

The client has a urine output of 120 mL over 4 hours.: While decreased urine output can be a concerning sign, it is not the most signiﬁcant ﬁnding to report in a hypertensive emergency. In this scenario, the focus is on acute complications related to high blood pressure, such as organ damage or impending stroke, which require immediate attention.

In summary, the ﬁnding that is most important to report to the healthcare provider in a client with a hypertensive emergency is the presence of new-onset blurry vision and facial asymmetry. These symptoms suggest potential neurological involvement and the need for urgent medical intervention to prevent serious complications like stroke.

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Correct Answer is D

Explanation

An ABI of 0.89 indicates a reduced blood ﬂow to the lower extremities, which is suggestive of peripheral arterial disease (PAD). In PAD, there is narrowing or blockage of the arteries that supply blood to the legs and feet. Medications like clopidogrel and simvastatin are commonly prescribed for individuals with PAD to manage the condition and reduce the risk of complications.

Here's an explanation of why the other options are not the most appropriate interventions:

Document the information as a normal ﬁnding: An ABI of 0.89 is not considered a normal ﬁnding. An ABI value below 0.9 is generally indicative of PAD or reduced blood ﬂow to the lower extremities.

Prepare the client for an arterial bypass: An ABI value of 0.89 alone does not warrant immediate preparation for an arterial bypass. Arterial bypass surgery is typically considered for severe cases of PAD with signiﬁcant symptoms that signiﬁcantly impact the client's quality of life and other conservative treatments have not been successful.

Educate the client about the use of compression stockings: While compression stockings may be a part of the overall management of PAD, the ABI result alone does not indicate an immediate need for education about compression stockings. Other interventions, such as medication management, lifestyle modiﬁcations, and possibly revascularization procedures, may be more appropriate based on the severity of the PAD.

A. A client with a blood pressure of 190/92 mm Hg who reports chest pain B. A client with a blood pressure of 190/104 mm Hg who has sinus tachycardia C. A client with a blood pressure of 178/90 mm Hg who has intermittent claudication D. A client with a blood pressure of 172/98 mm Hg scheduled for a stress test

Correct Answer is A

Explanation

The nurse should assess the client with a blood pressure of 190/92 mm Hg who reports chest pain ﬁrst. Chest pain can be a symptom of myocardial ischemia or a heart attack, which requires immediate attention. The combination of high blood pressure and chest pain is concerning and may indicate acute coronary syndrome. Prompt assessment and intervention are crucial to evaluate the cause of the chest pain and initiate appropriate treatment.

A client with a blood pressure of 190/104 mm Hg who has sinus tachycardia: While sinus tachycardia may indicate increased heart rate, it does not necessarily require immediate assessment unless other concerning symptoms are present. However, the nurse should address the elevated blood pressure in a timely manner.

Intermittent claudication refers to leg pain or discomfort during physical activity due to reduced blood ﬂow. While it is important to assess and manage this symptom, it is not typically considered an urgent condition requiring immediate assessment compared to chest pain.

The client scheduled for a stress test may have elevated blood pressure, but if they are stable and not currently experiencing symptoms, they may not require immediate assessment compared to a client with chest pain.

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The nurse is assessing a client with a hypertensive emergency. Which ﬁnding is most important to report to the health care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client with a presumptive diagnosis of peripheral arterial disease. The nurse obtains an Ankle-Brachial index of 0.89. Which intervention should the nurse take next?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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