The nurse is developing a care plan for a client newly diagnosed with hypertension.
The nurse should include which of the following modifications in the client teaching plan of care?

Restricting sodium intake.

Stressing importance of follow-up and ophthalmic care.

Increasing intake of fruits and vegetables.

Taking prescribed medications as ordered.

Not taking medication when blood pressure is less than 140/90 mmHg.

Answer and Explanation

Correct Answer : A,B,C,D

Choice A rationale

Restricting sodium intake is essential as high sodium levels can increase fluid retention, leading to elevated blood pressure. A low-sodium diet reduces the workload on blood vessels and decreases the risk of cardiovascular complications associated with hypertension. The recommended sodium intake for adults should be less than 2,300 mg per day, and ideally closer to 1,500 mg daily for optimal blood pressure control.

Choice B rationale

Hypertension can lead to damage to the small blood vessels in the retina, resulting in hypertensive retinopathy. Stressing ophthalmic care ensures early detection and management of vision changes that may be indicative of ongoing vascular damage. Regular ophthalmologic evaluation aids in preventing irreversible vision loss and allows better management of systemic hypertension's effects on ocular health.

Choice C rationale

Increasing the intake of fruits and vegetables provides essential nutrients such as potassium, magnesium, and dietary fiber. Potassium helps counteract the effects of sodium and relaxes blood vessel walls, lowering blood pressure. The DASH diet, rich in fruits and vegetables, is widely recommended for individuals with hypertension to promote cardiovascular health and regulate blood pressure.

Choice D rationale

Taking prescribed medications as ordered ensures consistent management of blood pressure and prevention of complications such as stroke, heart attack, and kidney damage. Antihypertensive medications, including ACE inhibitors, beta-blockers, or diuretics, work through various mechanisms to lower blood pressure. Adherence prevents fluctuations and maintains target levels of less than 140/90 mmHg.

Choice E rationale

Not taking medication when blood pressure is less than 140/90 mmHg is incorrect because hypertension management requires consistent medication to maintain target levels and prevent rebound hypertension. Abrupt discontinuation can lead to complications such as severe hypertensive episodes and organ damage. Regular monitoring is crucial to guide therapy adjustments safely.

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Correct Answer is D

Explanation

Choice A rationale

Serum electrolytes provide valuable information about fluid and electrolyte balance but are not specific markers for heart failure. Electrolyte abnormalities, such as hyponatremia, may occur but are secondary findings. Direct markers like BNP levels are more diagnostic for heart failure.

Choice B rationale

A complete blood count is used to assess infection, anemia, or inflammation but does not directly diagnose heart failure. It lacks specificity for cardiac function evaluation. Targeted testing ensures effective diagnosis and management.

Choice C rationale

Blood urea nitrogen measures renal function and is not a primary marker for heart failure. Elevated BUN may result from renal hypoperfusion secondary to heart failure but is not a definitive diagnostic indicator. Specific cardiac markers are required.

Choice D rationale

Brain natriuretic peptide is a hormone released in response to ventricular stretch from volume overload, characteristic of heart failure. Elevated BNP levels strongly correlate with heart failure severity and guide diagnosis. Normal BNP levels are typically <100 pg/mL. This test is highly specific for heart failure. .

A. Ask if the client took any medication to treat the headache. B. Refer the client to see an eye specialist. C. Obtain the client's blood pressure. D. Obtain a full history and physical.

Correct Answer is C

Explanation

Choice A rationale

Asking about medication use for headaches provides insights into pain management strategies but does not directly address underlying causes of symptoms. Vision changes and headaches may indicate neurological or cardiovascular issues, which require immediate investigation of vital signs like blood pressure to rule out hypertension or increased intracranial pressure.

Choice B rationale

Referring the client to an eye specialist addresses vision changes but neglects the acute nature of headaches. Hypertension or elevated intracranial pressure can affect both vision and cause headaches, and immediate assessment of these factors through blood pressure is more urgent.

Choice C rationale

Obtaining blood pressure evaluates for hypertension, which can manifest with headaches and visual disturbances due to increased arterial pressure affecting cerebral and ocular vessels. Normal blood pressure ranges are typically 120/80 mmHg. Immediate blood pressure measurement prioritizes acute care and mitigates potentially life-threatening conditions.

Choice D rationale

Obtaining a full history and physical is valuable for comprehensive care but delays immediate assessment of critical symptoms such as visual changes and headaches. Measuring blood pressure provides faster evaluation of acute conditions like hypertensive crisis or stroke risk.

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The nurse is developing a care plan for a client newly diagnosed with hypertension.The nurse should include which of the following modifications in the client teaching plan of care?

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Naxlex Comprehensive Predictor Exams

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The nurse is developing a care plan for a client newly diagnosed with hypertension.
The nurse should include which of the following modifications in the client teaching plan of care?