Which are potential results of end-organ damage from chronic hypertension? (Select all that apply.)

Choice A reason: Overhydration is not the definition of the promotion of an adequate fluid balance, but rather a condition where the body has excess fluid volume, which can cause medical complications, such as edema, hyponatremia, or heart failure.
Choice B reason: Dehydration is not the definition of the promotion of an adequate fluid balance, but rather a condition where the body has insufficient fluid volume, which can cause medical complications, such as hypotension, tachycardia, or kidney failure.
Choice C reason: Hypernatremia is not the definition of the promotion of an adequate fluid balance, but rather a condition where the body has excess sodium concentration in the blood, which can cause medical complications, such as thirst, confusion, or seizures.
Choice D reason: Hydration is the definition of the promotion of an adequate fluid balance, as it refers to the maintenance of the optimal amount and distribution of fluid in the body, which can prevent medical complications, such as dehydration, electrolyte imbalance, or infection.

Choice A reason: Organize the reperfusion recombinant tissue plasminogen activator (tPA) infusion is not the appropriate step, as it is a treatment for acute ischemic stroke, which has not been confirmed in this client. tPA is a clot-busting drug that can restore blood flow to the brain, but it has strict criteria and time window for its use. The nurse should not assume that the client has a stroke without further assessment and diagnosis.

Choice B reason: Determine symptom onset or when the fall occurred is not the appropriate step, as it is not the priority for this client. The nurse should first assess the client's vital signs, neurologic status, and potential injuries from the fall. The symptom onset or fall time may be relevant for the diagnosis and treatment of the underlying cause, but it is not the most urgent information to obtain.

Choice C reason: Arrange for a transfer immediately to the radiology department is not the appropriate step, as it is not the most immediate intervention for this client. The nurse should first stabilize the client's condition, perform a thorough assessment, and obtain orders from the medical provider. The radiology department may be needed for diagnostic tests, such as computed tomography (CT) scan or magnetic resonance imaging (MRI), but it is not the first destination for this client.

Choice D reason: Perform a comprehensive neurologic assessment is the appropriate step, as it can help identify the possible cause of the client's balance problem and rule out a stroke or other serious condition. A neurologic assessment includes checking the client's level of consciousness, orientation, speech, cranial nerve function, motor strength, sensory perception, coordination, and reflexes. The nurse should also monitor the client's vital signs, oxygen saturation, and blood glucose levels.