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

A client with a blood pressure of 190/92 mm Hg who reports chest pain

A client with a blood pressure of 190/104 mm Hg who has sinus tachycardia

A client with a blood pressure of 178/90 mm Hg who has intermittent claudication

A client with a blood pressure of 172/98 mm Hg scheduled for a stress test

Answer and Explanation

The Correct Answer is A

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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A bruit is a sound that can be heard with a stethoscope when blood flows through a narrowed or damaged artery. An abdominal bruit may indicate an abdominal aortic aneurysm (AAA), which is a bulge or swelling in the main blood vessel that runs from the heart down through the chest and tummy.

Shortness of breath is a common symptom of many conditions, but it is not specific to AAA. It can be caused by heart or lung problems, anemia, anxiety, lack of exercise, obesity, and many other factors. Shortness of breath may occur with a ruptured AAA, but it is not a reliable sign of an intact AAA.

Ripping abdominal pain is a severe and sudden pain that may indicate a ruptured AAA, which is a life-threatening situation that requires immediate medical attention. However, an intact AAA usually does not cause any pain or discomfort. Therefore, ripping abdominal pain is not a good indicator of an AAA diagnosis.

Decreased urinary output is a sign of reduced kidney function, which can have many causes such as dehydration, kidney failure, urinary tract obstruction, or medication side effects. Decreased urinary output is not directly related to AAA, although it may occur as a complication of a ruptured AAA or surgery to repair an AAA.

A. Most people are able to control BP through dietary changes. B. Increasing physical activity controls blood pressure (BP) for most people. C. Annual BP checks are needed to monitor treatment effectiveness. D. Hypertension is usually asymptomatic until target organ damage occurs

Correct Answer is D

Explanation

Hypertension, or high blood pressure, is often referred to as the "silent killer" because it typically does not cause noticeable symptoms until it has already caused damage to target organs such as the heart, blood vessels, kidneys, or brain. It is crucial for the client to understand that even if they do not experience symptoms, untreated or poorly controlled hypertension can lead to serious complications, including heart disease, stroke, kidney problems, and more.

While dietary changes and increasing physical activity are important lifestyle modifications for managing hypertension, it is not accurate to state that most people can control their blood pressure through these measures alone. Hypertension is a complex condition influenced by multiple factors, and many individuals require additional interventions, such as medication, to effectively manage their blood pressure.

Annual blood pressure checks are indeed important to monitor the effectiveness of treatment and ensure that blood pressure remains within the target range. However, this information is secondary to the understanding that hypertension is typically asymptomatic until target organ damage occurs.

Recognizing the potential risks associated with untreated or uncontrolled hypertension can motivate the client to adhere to their treatment plan and make necessary lifestyle changes.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is admitting a client with Abdominal aortic aneurysm. Which assessment data would support the diagnosis?

Correct Answer is B

Explanation

Which information is most important for the nurse to include when teaching a client newly diagnosed with hypertension?

Correct Answer is D

Explanation

The nurse is providing discharge education to a client with hypertension. Which essential information should the nurse include in the teaching plan?

A nurse is assessing a client with a history of high blood pressure. The client's blood pressure is 210/106 mm Hg during the assessment. What follow-up question should the nurse ask?

A nurse is preparing a client for scheduled transesophageal echocardiography. Which action should the nurse perform?

The nurse is performing a 12-lead ECG on a male client with abundant chest hair. What is the most appropriate nursing intervention to improve adhesion of the ECG leads?

The nurse is reviewing the medical electronic record of a client with abdominal aortic aneurysm less than 3 cm in size. Which medical treatment should the nurse anticipate to be prescribed for the client?

The nurse is caring for a client scheduled for a cardiac stress test at 1100. When the nurse enters the client's room at 0800, the client requests toast or at least some coffee. What is the best response?

The nurse is caring for a client immediately after repair of an abdominal aortic aneurysm. On assessment, the client has absent popliteal, posterior tibial, and dorsalis pedis pulses. The leg cool and mottled. Which action should the nurse take ﬁrst?

The nurse has written a plan of care for a client diagnosed with peripheral arterial insufficiency. Which intervention is the most appropriate for this diagnosis?