The nurse on the intermediate care unit received a change-of-shift report on four patients with hypertension. Which patient should the nurse assess first?

52-yr-old with a blood pressure of 198/90 mm Hg who has intermittent claudication.

48-yr-old with a blood pressure of 160/92 mm Hg who reports chest pain.

43-yr-old with a blood pressure of 172/98 mm Hg whose urine shows microalbuminuria.

50-yr-old with a blood pressure of 190/104 mm Hg who has a creatinine of 1.7 mg/dL.

Answer and Explanation

The Correct Answer is B

Among the four patients with hypertension, the nurse should assess the patient in option B first, the 48-year-old with a blood pressure of 160/92 mm Hg who reports chest pain.

Chest pain is a potentially serious symptom that could indicate an acute cardiac event, such as angina or a heart attack. Given that the patient has hypertension and is experiencing chest pain, the nurse must prioritize this assessment to rule out any cardiac-related complications or other urgent issues.

While all the other patients have elevated blood pressure readings, they have additional symptoms or conditions that indicate potential complications related to their hypertension. However, chest pain is a red flag that requires immediate attention and further assessment to determine its cause and provide appropriate interventions promptly.

Option A, the 52-year-old with a blood pressure of 198/90 mm Hg who has intermittent claudication, may have peripheral vascular disease or other vascular issues related to hypertension, but it is not as acutely concerning as chest pain.

Option C, the 43-year-old with a blood pressure of 172/98 mm Hg whose urine shows microalbuminuria, may have early signs of kidney involvement due to hypertension, which is significant and requires attention but may not be as immediately urgent as chest pain.

Option D, the 50-year-old with a blood pressure of 190/104 mm Hg who has a creatinine of 1.7 mg/dL, may have signs of kidney impairment related to hypertension, which is also significant but may not be as acutely urgent as chest pain.

In summary, the nurse should prioritize the assessment of the patient experiencing chest pain (option B) to address any potential cardiac-related issues promptly and ensure appropriate management and intervention.

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Correct Answer is B

Explanation

Jugular venous distention (JVD) is a clinical sign that indicates increased fluid volume or fluid overload in the cardiovascular system. When the head of the client's bed is elevated at 45 degrees, the jugular veins should normally be flat or slightly distended. However, if the jugular veins appear engorged and bulging, it suggests that there is an increased amount of blood returning to the right side of the heart and is unable to be efficiently pumped forward, leading to jugular venous distention.

JVD is commonly seen in conditions such as heart failure, where the heart's ability to pump blood efficiently is compromised, leading to fluid accumulation in the veins and eventually causing jugular venous distention.

Option A, jugular vein atherosclerosis, is not a common cause of JVD. Atherosclerosis refers to the build-up of plaque within arteries, not veins.

Option C, decreased fluid volume, would lead to dehydration and decreased venous filling, which would not cause jugular venous distention. It would lead to flat or sunken jugular veins.

Option D, incompetent jugular vein valves, would not cause jugular venous distention with the head of the bed elevated. Incompetent valves may lead to venous reflux or backward flow of blood, but it would not lead to the distention of the jugular veins in this position.

A. A 50-year-old white female with hypertension B. A 61-year-old Native American male with diabetes C. 40-year-old Hispanic female with cardiovascular disease D. A 28-year-old African American female with a urinary tract infection

Correct Answer is B

Explanation

Chronic kidney disease (CKD) is a condition where the kidneys are damaged or unable to filter blood effectively over time, leading to a gradual loss of kidney function. Several risk factors can increase the likelihood of developing CKD, and among them, diabetes and hypertension are the most common.

Diabetes is a significant risk factor for developing CKD. It can cause damage to the small blood vessels in the kidneys, impairing their ability to filter waste and fluid from the blood properly. Native Americans, along with other racial and ethnic minorities, are at a higher risk of developing diabetes compared to the general population.

While hypertension (high blood pressure) is also a risk factor for CKD, diabetes carries a higher risk. However, it's important to note that hypertension is often a comorbidity associated with CKD and can further worsen kidney function when present.

The other options listed (a 50-year-old white female with hypertension, a 40-year-old Hispanic female with cardiovascular disease, and a 28-year-old African American female with a urinary tract infection) are also at risk for CKD, but the 61-year-old Native American male with diabetes is at the highest risk based on the information provided. All patients should be educated about preventive measures to protect their kidney health, but special attention should be given to individuals with diabetes due to its significant impact on kidney function.

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The nurse on the intermediate care unit received a change-of-shift report on four patients with hypertension. Which patient should the nurse assess first?

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Naxlex Comprehensive Predictor Exams

While assessing an older adult client, the nurse notes jugular venous distention (JVD) with the head of the client's bed elevated 45 degrees. What does this finding indicate?

Correct Answer is B

Explanation

Which patient is most likely to develop chronic kidney disease (CKD) and should be taught preventive measures by the nurse?

Correct Answer is B

Explanation

Which assessment finding of a patient with chronic kidney disease indicates to the nurse that hemodialysis is having the desired effect?

The nurse is assessing a client who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider?

A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?

The nurse on the intermediate care unit received a change-of-shift report on four patients with hypertension. Which patient should the nurse assess first?

Which diagnostic test will be most useful to the nurse in determining whether a client admitted with acute shortness of breath has heart failure?

Which statement by a client with newly diagnosed heart failure indicates to the nurse that teaching was effective?

After receiving change-of-shift report on a heart failure unit, which client should the nurse assess first?

A nurse is providing dietary teaching to a client who has chronic kidney disease (CKD). The nurse should instruct the client to limit which of the following nutrients? (Select all that apply.)