Hypertension
Which topic would be the most important to include in teaching when an obese client receives a diagnosis of high blood pressure?
A. Causes of hypertension
B. Symptoms of hypertension
C. Effect of weight loss in hypertension
D. Effect of lowering alcohol intake in hypertension
Weight loss is among the most powerful lifestyle modifications in lowering blood pressure. Because teaching should be individualized to the client, the effect of weight loss would be emphasized for this obese client. The other topics might also be addressed, but they are not as specific to the client. Causes of hypertension would be discussed, but with an emphasis on the effect of high weight in causing high blood pressure. Symptoms of hypertension (such as headaches and nose bleeds) would be discussed, but many clients do not have symptoms until they develop cardiovascular complications of hypertension. Limiting alcohol intake to 2 drinks a day for men and 1 drink per day for women and smaller men is recommended, but there is no indication that this client has a high alcohol intake.
Which action would the nurse take when a client with chronic venous insufficiency has ankle edema?
A. Restrict fluids.
B. Elevate the legs.
C. Apply a Unna boot.
D. Discuss sclerotherapy.
Elevation of extremities promotes venous and lymphatic drainage by gravity. Restricting fluids is not indicated for edema caused by venous insufficiency (although it might be used for edema caused by heart failure). Unna boots are used to treat venous stasis ulcers. Sclerotherapy is used for treatment of varicose veins.
A nurse is assessing a client who is suspected of having hypovolemia. Which of the following findings should the nurse expect?
A. Bounding pulse and hypertension
B. Moist mucous membranes and increased urine output
C. Weak, thready pulse and orthostatic hypotension
D. Jugular vein distention and crackles in the lungs
Hypovolemia, or fluid volume deficit, typically results in signs of decreased circulating volume. A weak, thready pulse and orthostatic hypotension occur due to reduced venous return and cardiac output. The other options reflect signs of fluid overload (bounding pulse, hypertension, moist mucous membranes, jugular vein distention, and crackles in the lungs) or adequate hydration, which would not be present in hypovolemia.
How do microorganisms reach the lungs and cause pneumonia (Select All That Apply)?
A. Aspiration
B. Lymphatic spread
C. Inhalation of microbes in the air
D. Touch contact with infectious microbes
E. Hematogenous spread from infections elsewhere in the body
Aspiration of normal flora from nasopharynx or oropharynx
Inhalation of microbes present in the air
Hematogenous spread from primary infection elsewhere in body
When looking at an ECG strip, the nurse notes the "t wave" is peaked. Which electrolyte imbalance is suspected in the client?
A. Hypokalemia
B. Hypercalcemia
C. Hyperkalemia
D. Hypomagnesia
Peaked T waves are characteristic of hyperkalemia.
Which effect would the nurse anticipate after captopril is prescribed for a client?
A. Increased urine output
B. Decreased anxiety
C. Improved sleep
D. Decreased blood pressure
Captopril is an angiotensin-converting enzyme (ACE) inhibitor antihypertensive. It does not have diuretic, sedative, or hypnotic properties. Diuretics promote fluid excretion. Sedatives reduce muscle tension and anxiety. Hypnotics promote sleep.
Which response would the nurse give when a client with varicose veins asks the nurse, "What can I do to help myself?"?
A. "Limit walking to as little as possible."
B. "Reduce fluid intake to 1 L of liquid a day."
C. "Apply moisturizing lotion on your legs several times a day."
D. "Put on compression hose before getting out of bed in the morning."
Compression hose provides external pressure, thereby facilitating venous return and minimizing blood pooling in the veins. Because venous return is better at night when the legs are at the same level as the heart, the hose should be put on before getting out of bed in the morning and before the legs are in the dependent position. The client should engage in exercise such as walking or swimming because muscle contraction encourages venous return to the heart. Limiting fluid intake will not alter the leakage of fluid or blood into the interstitial space; this occurs in response to the increased hydrostatic pressure in the veins. Although applying moisturizing lotion may make the skin suppler, it will not treat enlarged and tortuous veins.
A nurse is caring for a client with a serum sodium level of 125 mEq/L. Which of the following assessments is the priority?
A. Monitor for muscle cramps and weakness
B. Observe for decreased deep tendon reflexes
C. Evaluate for confusion and neurological changes
D. Check for dry mucous membranes and poor skin turgor
Hyponatremia (serum sodium <135 mEq/L) can lead to cerebral edema due to fluid shifting into brain cells, resulting in neurological symptoms such as confusion, headache, seizures, and potentially coma. While muscle weakness, decreased reflexes, and signs of dehydration can also occur, neurological changes are the most critical and life-threatening complication, making them the priority for assessment and intervention.
Tobacco smoke causes deficits in multiple areas of the respiratory system. What is a long-term effect of smoking?
A. Bronchospasm and hoarseness
B. Decreased mucus secretions and cough
C. Increased function of alveolar macrophages
D. Increased risk of infection and hyperplasia mucous glands
Cigarette smoking causes lung infections by damaging the respiratory epithelium, which acts as a protective barrier in the respiratory tract, compromising immunity, making the body more vulnerable to infections. Goblet cell hyperplasia increases mucus production.
The nurse is caring for a chronic obstructive pulmonary disease (COPD) client with cor pulmonale. The nurse expects which finding?
A. Chest pain
B. Persistent hypertension
C. Peripheral edema
D. Elevated temperature
Cor pulmonale, a type of right-sided heart failure, leads to edema primarily due to increased pressure in the venous system and subsequent fluid leakage into surrounding tissues. The failing right ventricle cannot efficiently pump blood to the lungs, causing a backup of blood in the veins returning to the heart. This backup increases pressure in the capillaries, forcing fluid out and into the body, causing swelling (edema).
Which topic would the nurse include in teaching for a client with a new diagnosis of hypertension? Select all that apply.
A. Reason for daily low-dose aspirin use
B. Use of a home blood pressure monitor
C. Adverse effects of tobacco on blood pressure
D. Avoidance of any alcohol consumption
E. Benefits of moderate daily exercise
Lifestyle management of blood pressure includes monitoring blood pressure at home frequently using a home blood pressure monitor, avoiding tobacco products, and a physically active lifestyle that includes moderate daily exercise. Daily aspirin is not recommended for clients who have hypertension, although it may be recommended for clients with known coronary artery disease or additional risk factors for cardiovascular disease. Although excessive alcohol use should be avoided, moderate alcohol consumption (2 alcoholic drinks/day for men and 1 alcoholic drink/day for women and lighter-weight men) is acceptable for clients with hypertension.
Which laboratory value will be important for the nurse to monitor to determine whether a client with chest pain has acute coronary syndrome (ACS)?
A. Troponin T (cTnT)
B. C-reactive protein (CRP)
C. Low-density lipoprotein (LDL)
D. B-type natriuretic protein (BNP)
Cardiac troponins are released into circulation within hours after myocardial injury or infarction, and elevation in troponin levels helps determine that the client is experiencing ACS. The other three values will also be monitored but are not markers for ACS or acute myocardial infarction. C-reactive protein is a marker for inflammation and elevated levels can predict cardiac disease. Elevated LDL is a risk factor for atherosclerosis and coronary artery disease. Elevated BNP is diagnostic for heart failure.
A nurse is providing dietary teaching to a client with hypokalemia. Which of the following food choices indicates the client understands the teaching?
A. White rice and apple juice
B. Baked chicken and green beans
C. Tomatoes and baked potato
D. Toast with butter and scrambled eggs
Tomatoes and baked potatoes are excellent sources of potassium, which is essential for managing hypokalemia. Clients with low potassium levels should be encouraged to consume potassium-rich foods. The other options contain lower amounts of potassium and would not be as effective in correcting a potassium deficit.
The nurse teaches a client with asthma to use a peak flow meter. Which action by the client indicates that teaching was successful?
A. The client inhales rapidly through the peak flowmeter mouthpiece.
B. The client takes salmeterol for peak flows in the red zone.
C. The client uses albuterol for peak flows in the yellow zone.
D. The client calls the health care provider when the peak flow is in the green zone
Clients blow out forcefully into a peak flow meter. Red is the danger zone. Using a short-acting bronchodilator would be best and to get treatment STAT. Yellow zone means asthma is getting worse. A short-acting bronchodilator such as albuterol is needed for symptom relief. The green is no symptoms.
Which diagnostic study is used to diagnose mitral valve prolapse?
A. Electrocardiogram
B. Cardiac catheterization
C. CT scan of the chest with contrast
D. 2-D echocardiography
An echocardiogram is a diagnostic study that is used to diagnose mitral valve prolapse. All echocardiograms are done in two or three dimensions. An echocardiogram is used to monitor the progression of valvular heart disease. An electrocardiogram is used to identify heart rate, rhythm, ischemia, or ventricular hypertrophy. Cardiac catheterization is used to detect pressure changes in the cardiac chambers. A CT scan of the chest with contrast is the gold standard for evaluating aortic disorders.
Which instruction would the nurse give an unlicensed assistive personnel (UAP) to perform while caring for a client prescribed captopril? Select all that apply.
A. Obtain blood pressure.
B. Measure intake and output.
C. Weigh the client every morning.
D. Notify the nurse if the client has a dry cough.
E. Assist the client to change positions slowly.
ACE inhibitors such as captopril are prescribed for the management of hypertension, heart failure, and diabetic nephropathy. The nurse would ask the UAP caring for a client taking captopril to perform several tasks. The UAP would obtain the client’s blood pressure. The UAP would also measure the client’s intake and output as well as obtain a daily weight in the morning. This data would help the nurse determine the client’s fluid volume status and is an important component of heart failure management. The UAP would be aware that a dry cough is a common side effect of ACE inhibitors. Because of the blood pressure–lowering effects of this medication, the nurse would instruct the UAP to assist the client to make sure the client changes positions slowly.
Which question will be relevant to ask when obtaining the health history of a client with mitral valve stenosis?
A. "Do you frequently get urinary tract infections?"
B. "Have you had a recent episode of pneumonia?"
C. "Did you ever have strep throat during childhood?"
D. "Do you have a family history of heart attack or angina?"
Streptococcal infections occurring in childhood may result in damage to heart valves, particularly the mitral valve. Group A streptococcal antigens bind to receptors on heart cells, where an autoimmune response is triggered damaging the heart. The nurse may obtain information about other infections, but urinary tract infection is not associated with risk for mitral stenosis. Mitral stenosis does not increase pneumonia risk and is not caused by recent pneumonia. The nurse may ask about a family history of heart disease, but a history of coronary artery disease or myocardial infarction does not increase the risk for valve disease.
A nurse is assessing a client with hypocalcemia. Which of the following findings should the nurse expect?
A. Positive Chvostek’s sign and tingling around the mouth
B. Constipation and deep bone pain
C. Flushed skin and decreased deep tendon reflexes
D. Bradycardia and hypoactive bowel sounds
Hypocalcemia increases neuromuscular excitability, leading to tetany, tingling (especially around the mouth and fingertips), and positive Chvostek’s and Trousseau’s signs. The other options describe signs more consistent with hypercalcemia, such as constipation, bradycardia, and decreased reflexes.
A nurse is caring for a child with cystic fibrosis (CF). Which of the following nursing interventions is the priority to help prevent respiratory complications?
A. Administer pancreatic enzyme supplements with meals
B. Encourage increased fluid intake
C. Perform chest physiotherapy as ordered
D. Monitor for signs of malnutrition
Airway clearance techniques such as chest physiotherapy are the priority to prevent respiratory complications, which are the leading cause of morbidity and mortality in CF. These techniques help loosen and mobilize thick mucus in the lungs, reducing the risk of infection and improving oxygenation.
Which response would the nurse make to a 30-year-old client diagnosed with hyperlipidemia and hypertension who asks the nurse to explain why treatment is important, stating "I feel fine, so I don’t really see the need to make any changes."?
A. "Both high blood pressure and high cholesterol contribute to development of heart disease."
B. "Lifestyle adaptations alone will be adequate as long as you continue to be asymptomatic."
C. "Usually someone with these diagnoses will have symptoms of heart disease already."
D. "You should discuss your questions about medical problems with the health care provider."
Because cardiac risk factors are cumulative in their effect on the development of coronary artery disease, treatment of both risk factors is advised before development of symptoms. Although lifestyle adaptations are an initial action in management of hypertension and hyperlipidemia, treatment with medications is also frequently required. The majority of young adults with hypertension and hyperlipidemia are asymptomatic. Although the health care provider will certainly answer questions, the nurse is also responsible for teaching clients about how to manage cardiac risk factors.
Which interventions should the nurse take to ensure the well-being of a community-dwelling older adult with hypertension? Select all that apply. One, some, or all responses may be correct.
A. Suggest that the client have annual Papanicolaou (Pap) smears and mammograms.
B. Promote dietary modifications by using varied techniques.
C. Assess the client’s current lifestyle and promote lifestyle changes.
D. Monitor the client’s blood pressure and weight, and establish blood pressure screening programs.
E. Teach the client about correct body mechanics and the availability of mechanical appliances.
When caring for a community-dwelling older adult with hypertension, the nurse would promote dietary modifications, assess a client’s current lifestyle and promote lifestyle changes, and monitor the client’s blood pressure and weight and establish blood pressure screening programs. While suggesting annual Papanicolaou (Pap) smears and mammograms is beneficial, it is not specific for hypertension. When caring for a community-dwelling older adult with arthritis, the nurse would teach the client about correct body mechanics and the availability of mechanical appliances.
Which condition would the nurse conclude that the client is experiencing when the monitor shows a PQRST wave for each beat, indicates a rate of 120 beats per minute, and the rhythm is regular?
A. Atrial fibrillation
B. Sinus tachycardia
C. Ventricular fibrillation
D. First-degree atrioventricular block
Sinus tachycardia
Correct answer
Ventricular fibrillation
First-degree atrioventricular block
The presence of a P wave before each QRS complex indicates a sinus rhythm. A heart rate greater than 100 beats per minute indicates tachycardia. Atrial fibrillation causes an irregular rhythm, and P waves are not identifiable. Ventricular fibrillation is irregular and shows no PQRST configurations. A first-degree atrioventricular block pattern has a prolonged PR interval and is regular.
A nurse is caring for a client with hypervolemia. Which of the following provider prescriptions should the nurse question?
A. Monitor intake and output every 4 hours
B. Administer furosemide 20 mg IV once
C. Encourage oral fluid intake to 3,000 mL/day
D. Elevate the head of the bed to 45 degrees
In hypervolemia, the goal is to reduce fluid volume, not increase it. Encouraging a high fluid intake would worsen the condition and is inappropriate. The other options are appropriate: monitoring I&O helps track fluid status, diuretics like furosemide assist in removing excess fluid, and elevating the head of the bed helps ease breathing in clients with fluid overload and possible pulmonary congestion.
A nurse is caring for a toddler recently diagnosed with pertussis. Which of the following treatments should the nurse expect to be prescribed to reduce disease transmission?
A. Oral corticosteroids
B. Albuterol inhaler
C. Azithromycin
D. Acetaminophen
Azithromycin, a macrolide antibiotic, is the treatment of choice for pertussis. It helps reduce the severity of symptoms if started early and, most importantly, limits the spread of infection to others by eliminating the Bordetella pertussis bacteria.
Which finding for a client with pulmonary edema who received furosemide is the best indicator that the treatment has been effective?
A. Urine output over 1 hour is 200 mL.
B. Oxygen saturation per pulse oximetry is 99%.
C. Cardiac monitor shows sinus rhythm, rate 98 beats/minute.
D. No jugular vein distention is seen with head elevated to 90 degrees.
Because pulmonary congestion associated with pulmonary edema causes severe hypoxemia, the client’s oxygen saturation is the best indicator of effective treatment. A good urine output also shows that furosemide is effective, but is not as clear an indicator of improvement in pulmonary edema as the high oxygen saturation. Tachycardia is a common finding with pulmonary edema and having a heart rate in the high normal range may indicate improvement in the client’s condition, but improvement in pulmonary parameters is a better indicator for this client. Jugular vein distension is an indicator of right heart failure, whereas pulmonary edema is caused by left ventricular failure.