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

Choice A reason: This is the correct answer because the nurse should assess the patient's pain level and location, even if he denies pain. The patient's vital signs indicate that he may be experiencing pain, as increased heart rate, respiration rate, and blood pressure are common physiological responses to pain. Pain can also be masked by other factors, such as fear, anxiety, or stoicism. Therefore, the nurse should ask the patient about his comfort and use a valid pain assessment tool, such as the numeric rating scale or the faces pain scale, to measure his pain intensity.

Choice B reason: This is incorrect because the nurse should not administer an opioid medication by IV route without assessing the patient's pain level and location first. Opioid medications are potent analgesics that can relieve severe pain, but they can also cause serious side effects, such as respiratory depression, sedation, nausea, vomiting, constipation, or dependence. The nurse should follow the principles of pain management, such as using the lowest effective dose, titrating the dose according to the patient's response, and monitoring the patient for adverse effects. The nurse should also consider using non-pharmacological interventions, such as ice packs, elevation, or distraction, to complement the pharmacological therapy.

Choice C reason: This is incorrect because the nurse should not check the surgical dressing for bleeding without assessing the patient's pain level and location first. Checking the surgical dressing for bleeding is an important intervention to monitor the patient's wound healing and prevent infection, but it is not the priority in this scenario. The nurse should first assess the patient's pain and provide appropriate pain relief, as pain can impair wound healing and increase the risk of complications. The nurse should also obtain the patient's consent and explain the procedure before checking the surgical dressing, as this can cause discomfort and anxiety.

Choice D reason: This is incorrect because the nurse should not report the vital signs to the health care provider without assessing the patient's pain level and location first. Reporting the vital signs to the health care provider is an important intervention to communicate the patient's condition and obtain further orders, but it is not the priority in this scenario. The nurse should first assess the patient's pain and provide appropriate pain relief, as pain can affect the vital signs and the patient's well-being. The nurse should also document the patient's pain assessment and intervention in the medical record, as this can facilitate the continuity of care and evaluation of outcomes.

Choice A reason: This statement is incorrect because wellness is not only dependent on the absence of disease, but also on the physical, mental, emotional, social, and spiritual aspects of health. The nurse should educate the client on how to cope with his condition and enhance his quality of life, not focus on the negative aspects of his disease.

Choice B reason: This statement is incorrect because aggressive medical interventions may not be appropriate or beneficial for a terminally ill client. The nurse should respect the client's wishes and preferences regarding his care, and provide comfort and palliative measures, not cause unnecessary pain or suffering.

Choice C reason: This statement is incorrect because wellness is still a real option for a terminally ill client. The nurse should not assume that the client has given up on his health or happiness, but rather support him in finding meaning and purpose in his life, and achieving his goals and values.

Choice D reason: This statement is correct because it reflects the nurse's role in promoting wellness for a terminally ill client. The nurse should provide nursing interventions that can help the client maintain his dignity, autonomy, and sense of control, as well as address his physical, emotional, social, and spiritual needs. The nurse should also empower the client to make informed decisions about his care, and facilitate his communication with his family and health care team.