The nurse is teaching a client about some of the health consequences of uncontrolled hypertension. What health problems should the nurse describe. (SELECT ALL THAT APPLY)
Retinal Hemorrhage
Ventricular hypertrophy
Cerebrovascular Disease
Venous insufficiency
Transient Ischemic Attacks (TIAs)
Correct Answer : A,B,C,E
A. Retinal Hemorrhage
Uncontrolled hypertension can damage the blood vessels in the eyes, leading to retinal hemorrhages. This can result in vision problems and, in severe cases, vision loss.
B. Ventricular Hypertrophy
Uncontrolled hypertension causes the heart to pump against increased resistance, leading to the thickening and enlargement of the left ventricle. Ventricular hypertrophy is a response to the increased workload on the heart and is associated with an increased risk of heart failure.
C. Cerebrovascular Disease
Hypertension is a major risk factor for cerebrovascular diseases, including strokes. Elevated blood pressure can damage the blood vessels in the brain, increasing the risk of stroke. Strokes can have serious consequences, affecting various neurological functions.
D. Venous Insufficiency
Venous insufficiency is not typically directly associated with uncontrolled hypertension. It is more commonly related to problems with the venous system, such as damaged valves in the veins, leading to poor blood flow back to the heart. While hypertension can affect arteries, venous insufficiency is a distinct condition.
E. Transient Ischemic Attacks (TIAs)
Uncontrolled hypertension increases the risk of transient ischemic attacks (TIAs), which are brief episodes of neurological dysfunction caused by temporary disruption of blood flow to the brain. TIAs are often considered warning signs of an increased risk of stroke.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
A. Limit physical activity
Limiting physical activity is not a primary goal in heart failure care. In fact, promoting appropriate and monitored physical activity is often part of the overall management plan. Exercise, when tailored to the client's condition, can improve functional status and quality of life.
B. Prevent endocarditis
While preventing endocarditis is important for individuals with certain cardiac conditions, it is not a primary goal in the care of heart failure. The focus is typically on optimizing cardiac function and managing heart failure symptoms.
C. Relieve the patient’s symptoms
Managing and relieving symptoms, such as dyspnea, fatigue, and fluid retention, are crucial goals in heart failure care. This includes optimizing medication management and other therapeutic interventions.
D. Extend survival
While heart failure is a chronic condition, the goal is to optimize treatment to improve the client's prognosis and overall survival. This involves the use of evidence-based therapies to address the underlying causes and contributing factors.
E. Improve functional status
Enhancing the client's ability to perform activities of daily living and improving functional capacity are important goals. This can involve a combination of medications, lifestyle modifications, and rehabilitation.
Correct Answer is ["A","B","C","D"]
Explanation
A. Normal sinus rhythm that becomes sinus tachycardia
Sinus tachycardia can be an indication of increased sympathetic activity in response to decreased cardiac output. It may suggest the heart's compensatory response to maintain adequate perfusion.
B. Onset of a cough with pink, frothy sputum
Pink, frothy sputum is a classic sign of pulmonary edema, which can occur in the setting of worsening heart failure. It indicates the presence of blood-tinged fluid in the alveoli.
C. Presence of dyspnea at rest
Dyspnea at rest suggests that the client is experiencing difficulty breathing even without physical exertion. This can be indicative of more severe heart failure.
D. Falls asleep when not disturbed
Falling asleep when not disturbed may indicate fatigue or exhaustion, which is common in individuals with heart failure. However, it is not a direct indicator of worsening heart failure and can be influenced by various factors.
E. Urine drainage is increased in amount
Increased urine output can be a sign of diuretic therapy or an attempt by the body to compensate for fluid overload. However, it is essential to consider other factors such as renal function and medication effects.
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