Question

A 58-year-old patient with chronic kidney disease and newly diagnosed hypertension is admitted to the clinic. Which nursing action best reflects an understanding that this patient's hypertension is secondary?

Answer 1

Correct Answers:

Prioritize managing the underlying kidney disease to control blood pressure.

Rationale :

🔷 Secondary hypertension means the elevated blood pressure is caused by an identifiable underlying condition, and in this case that condition is chronic kidney disease.

🔷 The kidneys play a major role in regulating fluid balance, sodium balance, and the renin-angiotensin-aldosterone system, all of which influence blood pressure.

🔷 If the underlying renal problem is not addressed, blood pressure may remain poorly controlled even if antihypertensive medication is started.

🔷 Effective care requires treating both the hypertension and its underlying cause, not just the symptom of high blood pressure.

🔷 Therefore, the nurse should prioritize management of the kidney disease to help control the blood pressure.

Focus on family history and obesity as main factors for hypertension management.

🔷 Family history and obesity are important in primary hypertension, but this client’s hypertension is linked to a specific secondary cause.

🔷 Focusing mainly on those factors would miss the key problem of renal disease.

Start antihypertensive medication without further investigation.

🔷 Antihypertensive medication may be necessary, but starting treatment without addressing the cause is incomplete care.

🔷 Secondary hypertension requires evaluation and management of the underlying condition.

Recommend lifestyle changes like increased exercise and diet modification only.

🔷 Lifestyle changes are helpful, but they are not enough when hypertension is due to chronic kidney disease.

🔷 The client needs management directed at the renal disorder as well.

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Answer 2

Correct Answers:

A patient who had recent surgery or injury
An elderly patient who is immobile for several days
A patient taking oral contraceptives or hormone replacement therapy
A patient recently diagnosed with COVID-19 Infection

Rationale :

A patient who had recent surgery or injury

💠 Recent surgery or injury increases the risk for venous thrombosis because tissue damage activates clotting mechanisms and may reduce mobility.

💠 Surgical procedures can injure blood vessels and create a hypercoagulable state.

💠 Immobilization after surgery also contributes to venous stasis, which is one of the major causes of thrombosis.

💠 This combination of vessel injury, reduced movement, and clotting activation significantly increases risk.

💠 Therefore, a client with recent surgery or injury is at increased risk for VT.

An elderly patient who is immobile for several days

💠 Immobility slows venous blood flow, especially in the lower extremities, which promotes venous stasis.

💠 Older adults are particularly vulnerable because circulation may already be less efficient and activity levels may be reduced.

💠 Prolonged bed rest is a well-known risk factor for deep vein thrombosis.

💠 Lack of muscle contraction in the legs reduces the normal pumping action that supports venous return.

💠 Therefore, an elderly patient who is immobile for several days is at increased risk.

A patient taking oral contraceptives or hormone replacement therapy

💠 Oral contraceptives and hormone replacement therapy can increase clotting tendency because estrogen affects coagulation factors.

💠 These medications are recognized risk factors for venous thromboembolism.

💠 The risk may be even higher when combined with smoking, immobility, or inherited clotting disorders.

💠 The nurse should assess medication history carefully when screening for VT risk.

💠 Therefore, a client taking these hormonal therapies is at increased risk.

A patient recently diagnosed with COVID-19 infection

💠 COVID-19 infection is associated with inflammation and a hypercoagulable state, which increases the risk of thrombosis.

💠 Many clients with COVID-19 develop clotting complications due to vascular inflammation and altered coagulation.

💠 This risk can exist even in clients who are not critically ill.

💠 Current nursing care recognizes COVID-19 as an important thrombotic risk factor.

💠 Therefore, a recently diagnosed COVID-19 infection increases the risk for VT.

A patient with a BMI of 28

💠 A BMI of 28 indicates overweight status, which may contribute somewhat to risk, but it is not the strongest option compared with the other major risk factors listed.

💠 The more clearly established VT risks here are surgery, immobility, hormone therapy, and COVID-19.

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Answer 3

Correct Answers:

Presence of a palpable, pulsatile mass in the abdomen

Rationale :

🟢 The most classic diagnostic indication of an abdominal aortic aneurysm (AAA) is a palpable, pulsatile abdominal mass.

🟢 This finding directly reflects abnormal dilation of the abdominal aorta.

🟢 Although some clients may also report abdominal, flank, or back discomfort, the pulsatile mass is the most specific physical sign.

🟢 It should be assessed carefully because forceful palpation can be dangerous if rupture is suspected.

🟢 Therefore, the presence of a palpable, pulsatile mass is the most important diagnostic indication of an AAA.

A widening pulse pressure

🟢 A widening pulse pressure may occur in some cardiovascular conditions, but it is not the most specific sign of AAA.

🟢 The pulsatile abdominal mass is more directly linked to the aneurysm itself.

Pt. complaints of nausea, vomiting and constipation

🟢 These gastrointestinal symptoms are nonspecific and can occur in many disorders.

🟢 They are not the most important diagnostic indication of an abdominal aortic aneurysm.

Sudden, stabbing abdominal pain that radiates to the back

🟢 Sudden severe pain radiating to the back is highly concerning for rupture or expansion, but it is not the most classic diagnostic indication overall.

🟢 The key physical sign of AAA is the pulsatile abdominal mass.

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Answer 4

Correct Answers:

Sinus tachycardia Increases myocardial oxygen demand, which may worsen myocardial ischemia in patients with CAD.

Rationale :

🟣 In sinus tachycardia, the heart beats faster, which increases the work of the myocardium and raises oxygen demand.

🟣 In a client with coronary artery disease, blood flow to the myocardium may already be reduced by narrowed coronary vessels.

🟣 The mismatch between oxygen supply and demand can worsen myocardial ischemia and increase the risk of chest pain or more serious cardiac events.

🟣 Tachycardia also shortens diastole, which reduces the time available for coronary artery perfusion.

🟣 Therefore, the nurse should closely monitor this client because sinus tachycardia can worsen ischemia in CAD.

Sinus tachycardia increases ventricular filling time, improving cardiac output in patients with CAD.

🟣 Sinus tachycardia actually decreases ventricular filling time because the heart is beating faster.

🟣 This can reduce efficiency rather than improve cardiac output in CAD.

Sinus tachycardia reduces the workload of the heart and improves coronary circulation in patient with CAD.

🟣 Tachycardia does not reduce cardiac workload; it increases it.

🟣 It can also reduce coronary perfusion time rather than improve it.

Sinus tachycardia decreases myocardial oxygen demand and may reduce coronary perfusion in patients with CAD.

🟣 Tachycardia does reduce coronary perfusion time, but it does not decrease myocardial oxygen demand.

🟣 It increases demand, which is the key danger in CAD.

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Answer 5

Correct Answers:

New onset right-sided weakness.

Rationale :

🟡 New neurologic changes after thoracic aortic aneurysm repair are an emergency because aortic clamping can compromise blood flow to the brain or spinal cord.

🟡 Right-sided weakness may indicate stroke, embolic event, or neurologic ischemia and requires immediate intervention.

🟡 Postoperative neurologic deficits are not expected findings and must be addressed without delay to prevent permanent damage.

🟡 The nurse should prioritize rapid assessment, provider notification, and further evaluation of the neurologic status.

🟡 Therefore, new onset right-sided weakness is the finding that requires immediate intervention.

Incisional pain rated 6/10.

🟡 Moderate incisional pain is expected after major surgery and should be treated, but it is not the most urgent finding here.

🟡 A new neurologic deficit is far more concerning.

Blood pressure 128/76 mm Hg.

🟡 A blood pressure of 128/76 mm Hg is within an acceptable range for many postoperative clients.

🟡 This does not indicate immediate instability in this situation.

Urine output of 40 mL/hr.

🟡 A urine output of 40 mL/hr is generally adequate for an adult and does not by itself suggest acute emergency.

🟡 The neurologic change is the priority.

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Answer 6

Correct Answers

Blank 1 Correct Option: time / amplitude
Blank 2 Correct Option: time / amplitude

Rationale :

🔷 On an ECG grid, the horizontal axis represents time, which helps the nurse measure the duration of electrical events in the heart.

🔷 This is how the nurse determines the heart rate, PR interval, QRS duration, and QT interval.

🔷 The vertical axis represents amplitude, which shows the strength or voltage of the electrical activity.

🔷 The height of the waveforms on the ECG reflects this amplitude and helps in interpreting the size of electrical signals.

🔷 Therefore, the correct terms are time on the horizontal axis and amplitude on the vertical axis.

depolarization / repolarization

🔷 Depolarization and repolarization are electrical processes of the heart, but they are not the labels of the ECG grid axes.

🔷 The grid itself is measured in time horizontally and amplitude vertically.

amplitude / time

🔷 This option reverses the correct order of the axes.

🔷 The horizontal axis is time, while the vertical axis is amplitude.

impulse / rate

🔷 Impulse and rate are not the standard terms used to describe the ECG grid axes.

🔷 ECG interpretation uses time and amplitude as the axis measurements.

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Answer 7

Correct Answers:

Encourage adherence to a low-sodium diet. regular physical activity, and limiting alcohol intake.

Rationale :

✅ This client has several important modifiable risk factors for primary hypertension, including a sedentary lifestyle, frequent alcohol use, and a diet high in processed foods.

✅ A low-sodium diet helps reduce fluid retention and vascular resistance, which can lower blood pressure.

✅ Regular physical activity improves cardiovascular health and supports weight and blood pressure control.

✅ Limiting alcohol intake is also essential because excess alcohol can contribute to elevated blood pressure.

✅ Therefore, the priority nursing intervention is to encourage a low-sodium diet, regular exercise, and Focus on educating about male sex and aging as non-modifiable risk factors for hypertension.

✅ Nonmodifiable factors are important to recognize, but they cannot be changed and should not be the priority intervention here.

✅ The client has several modifiable lifestyle factors that are more useful targets for nursing action.

Advise the client to increase protein intake and monitor blood pressure regularly.

✅ Monitoring blood pressure is important, but increasing protein intake is not the key lifestyle intervention for this client’s hypertension.

✅ Sodium reduction, exercise, and alcohol limitation are more directly relevant.

Recommend stress management techniques and evaluate family history for hypertension.

✅ Stress management may help, and family history is useful to know, but these do not address the client’s most significant modifiable contributors.

✅ The nurse should first focus on the major lifestyle factors already identified.

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Answer 8

Correct Answers:

0.18 seconds

Rationale :

🔷 The PR interval is measured from the beginning of the P wave to the beginning of the QRS complex.

🔷 On standard ECG paper, 1 small box = 0.04 seconds and 1 large box = 0.20 seconds.

🔷 In this tracing, the PR interval is about 4.5 small boxes, and 4.5 × 0.04 = 0.18 seconds.

🔷 This value is within the normal PR interval range of 0.12 to 0.20 seconds.

🔷 Therefore, the correct PR interval length is 0.18 seconds.

0.30 seconds

🔷 A PR interval of 0.30 seconds would equal about 7.5 small boxes, which is much longer than the interval shown.

🔷 This would also be abnormally prolonged and suggest a conduction delay such as first-degree AV block.

0.24 seconds

🔷 A PR interval of 0.24 seconds equals 6 small boxes, which is longer than the measured interval on this strip.

🔷 This value would also be slightly prolonged beyond the normal range.

0.04 seconds

🔷 A PR interval of 0.04 seconds equals only 1 small box, which is far too short for the tracing shown.

🔷 The visible PR interval clearly spans several small boxes, not just one.

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Answer 9

Correct Answers:

Arrhythmogenic Cardiomyopathy (ACM)

Rationale :

🔷 Arrhythmogenic cardiomyopathy is strongly associated with myocardial electrical instability, especially ventricular ectopy and ventricular tachycardia.

🔷 In this disorder, normal myocardium is replaced by fibrofatty tissue, which disrupts conduction pathways and creates an arrhythmogenic substrate.

🔷 This makes the ventricles more likely to generate abnormal impulses and dangerous dysrhythmias.

🔷 Clients can present with palpitations, syncope, or sudden cardiac death related to ventricular arrhythmias.

🔷 Therefore, ACM is the cardiomyopathy most commonly linked to ventricular ectopy and ventricular tachycardia.

Dilated Cardiomyopathy (DCM)

🔷 Dilated cardiomyopathy can cause arrhythmias, but it is not the classic cardiomyopathy most specifically known for marked ventricular electrical instability.

🔷 The stronger association with ventricular tachyarrhythmias is seen in arrhythmogenic cardiomyopathy.

Restrictive Cardiomyopathy

🔷 Restrictive cardiomyopathy is more strongly associated with impaired ventricular filling and diastolic dysfunction.

🔷 It is not the classic answer for prominent ventricular ectopy and ventricular tachycardia.

Stress (Takotsubo) Cardiomyopathy

🔷 Takotsubo cardiomyopathy is usually triggered by intense emotional or physical stress and is more often discussed in relation to transient left ventricular dysfunction.

🔷 Although dysrhythmias can occur, it is not the cardiomyopathy most characteristically associated with chronic ventricular electrical instability.

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Answer 10

Correct Answers:

Classify the patient as having stage 1 hypertension and initiate education on lifestyle modifications and monitoring.

Rationale :

💠 Classify the patient as having stage 1 hypertension and initiate education on lifestyle modifications and monitoring

💠 A blood pressure of 134/82 mm Hg falls within stage 1 hypertension under current guidelines, because the systolic pressure is between 130 and 139 mm Hg.

💠 Since this pattern has been noted across multiple clinic visits, it should not be dismissed as a single isolated elevation.

💠 The appropriate nursing action is to begin education on lifestyle modification, such as sodium reduction, exercise, weight management, and alcohol moderation, while continuing monitoring.

💠 Early recognition and intervention are important to reduce long-term cardiovascular risk.

💠 Therefore, this patient should be classified as having stage 1 hypertension with education and follow-up initiated.

Attribute the elevated reading to white coat hypertension and schedule home monitoring before making any clinical decisions.

💠 White coat hypertension may be considered in some cases, but repeated elevated office readings should not automatically be attributed to anxiety alone.

💠 The current readings already support classification and need intervention rather than dismissal.

Consider the blood pressure normal and advise no further action is necessary at this time.

💠 A reading of 134/82 mm Hg is not normal under current hypertension guidelines.

💠 No-action management would delay appropriate risk reduction.

Diagnose prehypertension and recommend routine annual blood pressure checks without intervention.

💠 The term prehypertension is outdated in current guideline language.

💠 This client meets criteria for stage 1 hypertension, which requires education and monitoring rather than only yearly checks.

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Custom Sp 26 2100 Exam 2

No.

1 :
A 58-year-old patient with chronic kidney disease and newly diagnosed hypertension is admitted to the clinic. Which nursing action best reflects an understanding that this patient's hypertension is secondary?

2 :
The nurse is assessing patients for risk factors associated with venous thrombosis (VT). Which patients are at increased risk for developing venous thrombosis? (Select All that Apply.)

3 :
Which of the following assessment findings is the most important diagnostic indication of an AAA?

4 :
The nurse is monitoring a patient on continuous ECG telemetry and notes that the patient has developed sinus tachycardia with a heart rate of 120beats/min. The patient has a history of coronary artery disease (CAD). Why should the nurse monitor this patient closely?

5 :
You are the nurse caring for a client in the intensive care unit following surgical repair of a thoracic aortic aneurysm (TAA). The surgeon explains that the aorta was clamped during the procedure. Which of the following postoperative findings requires immediate intervention?

6 :
Choose the correct terms to fill in the following two blanks in the order they appear.

Correct Answers

8 :
What is the length in seconds of the PR interval in the EKG complex below?

9 :
Which type of cardiomyopathy commonly causes myocardial electrical instability with ventricular ectopy and ventricular tachycardia?

10 :
A nurse is assessing a patient who consistently has a blood pressure reading of 134/82 mm Hg during multiple clinic visits. Based on current hypertension guidelines and the patient's readings, what is the most appropriate nursing interpretation and subsequent action?

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Custom Sp 26 2100 Exam 2

No.

1 : A 58-year-old patient with chronic kidney disease and newly diagnosed hypertension is admitted to the clinic. Which nursing action best reflects an understanding that this patient's hypertension is secondary?

2 : The nurse is assessing patients for risk factors associated with venous thrombosis (VT). Which patients are at increased risk for developing venous thrombosis? (Select All that Apply.)

3 : Which of the following assessment findings is the most important diagnostic indication of an AAA?

4 : The nurse is monitoring a patient on continuous ECG telemetry and notes that the patient has developed sinus tachycardia with a heart rate of 120beats/min. The patient has a history of coronary artery disease (CAD). Why should the nurse monitor this patient closely?

5 : You are the nurse caring for a client in the intensive care unit following surgical repair of a thoracic aortic aneurysm (TAA). The surgeon explains that the aorta was clamped during the procedure. Which of the following postoperative findings requires immediate intervention?

6 : Choose the correct terms to fill in the following two blanks in the order they appear.

Correct Answers

8 : What is the length in seconds of the PR interval in the EKG complex below?

9 : Which type of cardiomyopathy commonly causes myocardial electrical instability with ventricular ectopy and ventricular tachycardia?

10 : A nurse is assessing a patient who consistently has a blood pressure reading of 134/82 mm Hg during multiple clinic visits. Based on current hypertension guidelines and the patient's readings, what is the most appropriate nursing interpretation and subsequent action?

1 :
A 58-year-old patient with chronic kidney disease and newly diagnosed hypertension is admitted to the clinic. Which nursing action best reflects an understanding that this patient's hypertension is secondary?

2 :
The nurse is assessing patients for risk factors associated with venous thrombosis (VT). Which patients are at increased risk for developing venous thrombosis? (Select All that Apply.)

3 :
Which of the following assessment findings is the most important diagnostic indication of an AAA?

4 :
The nurse is monitoring a patient on continuous ECG telemetry and notes that the patient has developed sinus tachycardia with a heart rate of 120beats/min. The patient has a history of coronary artery disease (CAD). Why should the nurse monitor this patient closely?

5 :
You are the nurse caring for a client in the intensive care unit following surgical repair of a thoracic aortic aneurysm (TAA). The surgeon explains that the aorta was clamped during the procedure. Which of the following postoperative findings requires immediate intervention?

6 :
Choose the correct terms to fill in the following two blanks in the order they appear.

8 :
What is the length in seconds of the PR interval in the EKG complex below?

9 :
Which type of cardiomyopathy commonly causes myocardial electrical instability with ventricular ectopy and ventricular tachycardia?

10 :
A nurse is assessing a patient who consistently has a blood pressure reading of 134/82 mm Hg during multiple clinic visits. Based on current hypertension guidelines and the patient's readings, what is the most appropriate nursing interpretation and subsequent action?