Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown origin?

Explain the association between dysrhythmias and syncope.

Tell the patient about the benefits of implantable cardioverter-defibrillators.

Instruct the patient to call for assistance before getting out of bed.

Teach the patient about the need to avoid caffeine and other stimulants.

Answer and Explanation

The Correct Answer is C

For a patient admitted with syncopal (fainting) episodes of unknown origin, the most appropriate action to include in the plan of care is to instruct the patient to call for assistance before getting out of bed.

Syncope can be caused by various factors, including orthostatic hypotension (a drop in blood pressure upon standing) or cardiac-related issues. One of the common triggers for syncopal episodes is getting up from a lying or sitting position too quickly. By instructing the patient to call for assistance before getting out of bed, the nurse aims to prevent falls and potential injuries that may occur due to sudden fainting episodes.

While it's essential to educate the patient about potential causes of syncope (option A) and the benefits of implantable cardioverter-defibrillators (option B) if applicable to their condition, these actions may not directly address the immediate safety concern of preventing falls during syncopal episodes.

Option D, teaching the patient about the need to avoid caffeine and other stimulants, may be relevant if stimulants are identified as potential triggers for syncope in this particular patient. However, it is not the most critical action to include in the initial plan of care for a patient with syncopal episodes of unknown origin.

In summary, the top priority for the nurse is to ensure the safety of the patient by instructing them to call for assistance before getting out of bed to prevent falls during syncopal episodes until further evaluation and diagnosis can determine the cause of the fainting episodes.

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Correct Answer is B

Explanation

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.

A. Serum creatinine of 2.8 mg/dL B. Serum hemoglobin of 14.7 g/dL C. Blood glucose level of 96 mg/dL D. Serum potassium of 4.5 mEq/L

Correct Answer is A

Explanation

Among the given laboratory test results for a client with recently diagnosed hypertension, the most important result to communicate to the health care provider is option (A), "Serum creatinine of 2.8 mg/dL."

Serum creatinine is a measure of kidney function, and a value of 2.8 mg/dL indicates elevated creatinine levels. Elevated serum creatinine is a concerning finding, as it suggests decreased kidney function or kidney impairment. Hypertension can have a significant impact on the kidneys, and kidney damage is a common complication of uncontrolled high blood pressure.

The kidneys play a crucial role in regulating blood pressure by excreting waste products and excess fluids from the body. When kidney function is compromised due to hypertension, it can further worsen the blood pressure control, leading to a vicious cycle of kidney damage and worsening hypertension.

Option (B), "Serum hemoglobin of 14.7 g/dL," is within the normal range and does not indicate an immediate concern related to the client's hypertension.

Option (C), "Blood glucose level of 96 mg/dL," is also within the normal range for blood glucose and may not be directly related to the client's hypertension.

Option (D), "Serum potassium of 4.5 mEq/L," is within the normal range. While potassium levels are essential to monitor, they are not the most critical concern compared to kidney function in this context.

The elevated serum creatinine level suggests a potential complication of hypertension, namely kidney damage or decreased kidney function. Therefore, it is essential to communicate this finding promptly to the health care provider for further evaluation and appropriate management to address the client's kidney health and optimize blood pressure control.

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Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown origin?

Nursing Test Bank

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Correct Answer is A

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