The nurse is assessing a patient diagnosed with hypertension several years ago. What assessment finding may indicate that target organ damage is now occurring?
Changes in peristalsis
Decreased urine output
Decreased insulin resistance
Hypercholesteremia
The Correct Answer is B
A. Changes in peristalsis: Changes in peristalsis, which refers to the rhythmic contraction and relaxation of the gastrointestinal tract muscles, are not typically associated with target organ damage in hypertension. While hypertension can indirectly affect gastrointestinal function through its impact on other organ systems, such as the kidneys and cardiovascular system, alterations in peristalsis are more commonly attributed to gastrointestinal disorders or neurological conditions rather than hypertension-induced target organ damage.
B. Decreased urine output: In a patient diagnosed with hypertension, decreased urine output may indicate the development of target organ damage, particularly renal damage. Hypertension can lead to chronic kidney disease (CKD) over time, which is characterized by a gradual decline in kidney function. Decreased urine output may be a sign of impaired renal function, reduced glomerular filtration rate (GFR), or the presence of proteinuria. These changes indicate that the kidneys are no longer effectively filtering waste products and regulating fluid balance, suggesting the onset of renal damage as a consequence of long-standing hypertension.
C. Decreased insulin resistance: Hypertension is not directly linked to changes in insulin resistance. However, hypertension and insulin resistance are often comorbid conditions that share common risk factors, such as obesity, sedentary lifestyle, and unhealthy diet. While poorly controlled hypertension and insulin resistance can contribute to the development of cardiovascular disease and other complications, a decrease in insulin resistance would not typically be considered an indicator of target organ damage in hypertension.
D. Hypercholesterolemia: Hypercholesterolemia, or high levels of cholesterol in the blood, is a risk factor for cardiovascular disease, including atherosclerosis and coronary artery disease. While hypertension and hypercholesterolemia frequently coexist and contribute to the progression of vascular damage, the presence of hypercholesterolemia alone does not necessarily indicate target organ damage specific to hypertension. However, elevated cholesterol levels can exacerbate vascular changes and increase the risk of cardiovascular events in individuals with hypertension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Using appropriate personal protective equipment (PPE): Standard precautions include the use of PPE such as gloves, masks, gowns, and eye protection when caring for all patients, regardless of their known or suspected infectious status. This helps prevent the transmission of pathogens between the patient and the healthcare provider.
B. Placing patient in positive pressure isolation room: Placing a patient in a positive pressure isolation room is not a component of standard precautions. Positive pressure rooms are typically used for patients with compromised immune systems to protect them from exposure to airborne pathogens. Standard precautions should be followed regardless of the patient's room type.
C. Placing patient in contact precautions: Contact precautions involve specific measures to prevent the transmission of pathogens through direct or indirect contact with the patient or their environment. While contact precautions may be necessary for certain infectious diseases, they are not a component of standard precautions.
D. Wearing gloves at all times: While wearing gloves is part of standard precautions, it is not the only key element. Standard precautions also include other forms of PPE such as masks, gowns, and eye protection, as well as other infection control practices such as hand hygiene and environmental cleaning.
Correct Answer is A
Explanation
A. Reluctance to monitor blood pressure at home: One barrier to blood pressure management in patients newly diagnosed with hypertension is reluctance or resistance to monitor blood pressure at home. Home blood pressure monitoring is an essential component of hypertension management as it allows patients and healthcare providers to track blood pressure trends, assess the effectiveness of treatment, and make adjustments as needed. However, some patients may feel apprehensive about self-monitoring or may lack understanding of its importance, leading to reluctance to engage in this aspect of their care. Addressing this barrier requires patient education, encouragement, and support to promote the benefits of home blood pressure monitoring and empower patients to take an active role in managing their hypertension.
B. Reduction in work hours: While work-related stress and long working hours can contribute to hypertension, a reduction in work hours would not typically be considered a barrier to blood pressure management, especially if it allows for better stress management, lifestyle modifications, and adherence to treatment regimens.
C. Initiation of an exercise plan: Starting an exercise plan is generally considered a positive step in blood pressure management rather than a barrier. Regular physical activity helps lower blood pressure, improve cardiovascular health, and promote overall well-being. However, barriers related to exercise adherence, such as lack of time, motivation, or access to suitable facilities, could hinder effective blood pressure management.
D. Preference for a low sodium diet: Opting for a low sodium diet is beneficial for individuals with hypertension as it helps reduce blood pressure levels and lowers the risk of cardiovascular events. Therefore, a preference for a low sodium diet would not be considered a barrier to blood pressure management. However, barriers related to dietary adherence, such as taste preferences, cultural influences, or difficulty in meal planning, may need to be addressed to support long-term dietary changes and improve blood pressure control.
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