Which characteristic of a hypertensive crisis should the nurse recognize?

Occurrence of a headache or blurred vision.

Elevated cardiac enzymes.

Diastolic blood pressure less than 110 mm Hg.

Flattened jugular vein.

Answer and Explanation

The Correct Answer is A

A. The occurrence of a headache or blurred vision is correct. A hypertensive crisis is characterized by a sudden, severe elevation in blood pressure, often with diastolic readings above 120 mm Hg, and can lead to acute target organ damage. Neurological symptoms, such as severe headache, blurred vision, confusion, or seizures, are common clinical manifestations. These symptoms signal the urgency of intervention to prevent complications such as stroke or retinal damage.

B. Elevated cardiac enzymes are not a defining characteristic of a hypertensive crisis. While extremely high blood pressure can eventually cause cardiac injury or precipitate myocardial infarction, elevated enzymes indicate myocardial cell damage and are a secondary consequence, not a primary feature of the crisis itself.

C. A diastolic blood pressure less than 110 mm Hg is incorrect. Hypertensive crisis is defined by markedly elevated blood pressure, typically systolic greater than 180 mm Hg or diastolic greater than 120 mm Hg. A diastolic reading below 110 mm Hg does not meet the threshold for a hypertensive emergency or urgency.

D. A flattened jugular vein is unrelated to hypertensive crisis. Jugular vein distention typically reflects right-sided heart failure or increased central venous pressure, which are separate cardiovascular conditions. Flattening of the jugular vein would not be used to identify a hypertensive crisis.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Rolling both gloves off at the same time is not recommended, as it increases the risk of contamination. Proper glove removal involves peeling off one glove at a time, turning it inside out to avoid contact with contaminated surfaces.

B. Using two pairs of gloves (double-gloving) may be necessary for certain high-risk procedures, but it is not required for routine bedpan handling. The focus should be on proper technique rather than adding extra gloves unnecessarily.

C. Advising the UAP that the technique being used will result in hand contamination is correct. Sliding fingers inside the contaminated glove and rolling it off inappropriately can transfer pathogens to the skin. The nurse should correct the technique by teaching the proper method: grasp the outside of one glove at the wrist, peel it off inside out, then tuck it into the remaining glove and peel off the second glove inside out. This minimizes the risk of self-contamination and infection transmission.

D. Discarding gloves in the appropriate container is important, but the primary concern here is the incorrect removal technique, which poses an immediate contamination risk. Teaching correct removal takes priority over simply reminding where to discard gloves.

A. Adult respiratory distress syndrome with an oxygen saturation of 88% on room air. B. Chronic liver failure with a hemoglobin of 10.1 g/dL (101 g/L) and a slight bilirubin elevation. C. Myocardial infarction with sinus bradycardia and multiple ectopic beats. D. Pulmonary embolus with an IV heparin infusion and new onset hematuria.

Correct Answer is B

Explanation

A. Adult respiratory distress syndrome with an oxygen saturation of 88% on room air is unstable. Hypoxemia at this level requires intensive monitoring and possibly mechanical ventilation or high-flow oxygen, making the client unsafe for transfer to a lower-acuity medical unit.

B. Chronic liver failure with a hemoglobin of 10.1 g/dL (101 g/L) and a slight bilirubin elevation is stable enough for transfer. Although the client has mild anemia and liver enzyme changes, vital signs and overall stability are likely maintained, and this condition can be managed safely on a medical unit with routine monitoring and care.

C. Myocardial infarction with sinus bradycardia and multiple ectopic beats indicates ongoing cardiac instability. This client requires continuous cardiac monitoring, potential interventions for arrhythmias, and close hemodynamic observation, which cannot be safely provided outside the critical care unit.

D. Pulmonary embolus with an IV heparin infusion and new onset hematuria is unstable. The new hematuria suggests a bleeding complication, and the client requires close monitoring and potential adjustment of anticoagulation therapy in the critical care setting.

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Which characteristic of a hypertensive crisis should the nurse recognize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes an unlicensed assistive personnel (UAP) begin to remove exam gloves after emptying a bedpan containing feces. The UAP slides two fingers inside one of the gloves and begins to roll the glove off. Which action should the nurse implement?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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