Question

Which information is most important for the nurse to include when teaching a client newly diagnosed with hypertension?

Answer 1

Correct Answers:

Hypertension is usually asymptomatic until target organ damage occurs.

Rationale :

💠 Hypertension is a "silent killer" because clients often feel no symptoms until serious organ damage has already occurred.

💠 Target organs affected include the heart (left ventricular hypertrophy, HF), brain (stroke), kidneys (renal failure), and eyes (retinopathy).

💠 Teaching this fact ensures the patient understands the importance of adherence to therapy even when asymptomatic.

💠 It reinforces the need for lifelong monitoring and management rather than relying on symptoms to indicate worsening disease.

💠 Early recognition prevents complications such as MI, stroke, and renal failure, making this the most critical teaching point.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

"Have you consistently taken your medications?"

Rationale :

🔹 Hypertensive crisis (BP 238/118) is most commonly linked to non-adherence with antihypertensive medications.

🔹 Asking about compliance helps identify whether this is a preventable crisis due to skipped doses.

🔹 Many clients discontinue meds prematurely because they feel well, not understanding the long-term risks.

🔹 Medication history guides immediate interventions such as IV antihypertensives.

🔹 Identifying non-compliance also provides a chance for reinforcement of education and adherence strategies.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

The client cannot move the left arm and leg when asked to do so.

Rationale :

🟩 Sudden neurological deficits suggest an acute stroke due to end-organ damage from severe hypertension.

🟩 This is the most urgent finding because brain perfusion is compromised.

🟩 Immediate intervention (e.g., CT scan, thrombolysis evaluation) is critical for neurological recovery.

🟩 Headache and reduced urine are important but not as life-threatening as loss of motor function.

🟩 Reporting this ensures rapid response to prevent permanent disability.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

Serum creatinine of 2.8 mg/dL

Rationale :

⭐ Elevated serum creatinine signals impaired kidney function, which is a target organ effect of hypertension.

⭐ A level of 2.8 is well above the normal (0.6–1.3 mg/dL), suggesting significant renal impairment.

⭐ This requires immediate reporting to prevent further kidney damage or progression to chronic kidney disease.

⭐ Identifying renal damage guides changes in therapy, especially with ACE inhibitors and diuretics.

⭐ Early detection improves long-term outcomes and prevents end-stage renal disease.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

43-yr-old with a blood pressure of 172/98 mm Hg whose urine shows microalbuminuria.

Rationale :

🔺 Chest pain indicates possible myocardial ischemia or infarction, which is an emergency.

🔺 Even though the BP is not the highest, the symptom of chest pain makes this case the top priority.

🔺 Prompt assessment (ECG, troponin, oxygen) prevents life-threatening complications.

🔺 The principle of triage is symptoms over numbers—end-organ signs trump the actual BP value.

🔺 Early recognition prevents cardiac arrest and improves survival outcomes.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

Instruct the patient to call for assistance before getting out of bed.

Rationale :

⚫ Syncope places patients at high risk for falls and injury.

⚫ Safety is the immediate nursing priority before diagnostic teaching.

⚫ Encouraging call-for-assistance reduces chances of collapse when unsupervised.

⚫ Once safe, patient education about dysrhythmias can be reinforced.

⚫ This intervention addresses risk reduction, the first priority in nursing care.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

Start cardiopulmonary resuscitation (CPR).

Rationale :

🟤 Patient is pulseless and apneic despite monitor showing tachycardia—this is pulseless electrical activity (PEA).

🟤 CPR is the immediate life-saving action.

🟤 Defibrillation or cardioversion is ineffective in PEA; compressions restore perfusion.

🟤 Early CPR improves survival and neurological outcomes.

🟤 This aligns with ACLS guidelines for cardiac arrest management.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Increased fluid volume

Rationale :

⚪ Jugular venous distention (JVD) at 45° indicates elevated central venous pressure (CVP).

⚪ This is typically due to fluid overload or right-sided heart failure.

⚪ The finding is not normal in older adults and always signals pathology.

⚪ JVD correlates with venous congestion and impaired cardiac output.

⚪ Identifying this helps manage volume status with diuretics.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

Anticoagulant therapy

Rationale :

🟪 Atrial fibrillation increases risk of atrial thrombus and embolic stroke.

🟪 Anticoagulants (e.g., warfarin, DOACs) reduce this risk.

🟪 Even if rhythm persists, anticoagulation prevents life-threatening complications.

🟪 Education helps ensure compliance, as therapy is usually long-term.

🟪 This is critical for safety since cardiomyopathy patients already have poor cardiac output.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

Increase in the patient's heart rate.

Rationale :

🟩 Atropine is an anticholinergic drug that blocks vagal stimulation, increasing heart rate.

🟩 Used specifically for symptomatic bradycardia and AV blocks.

🟩 Effectiveness is seen when HR rises, improving cardiac output and perfusion.

🟩 No direct effect on PVCs or PACs—so HR is the only correct endpoint.

🟩 This demonstrates desired drug action and guides further monitoring.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Medsurg-390

No.

1 :
Which information is most important for the nurse to include when teaching a client newly diagnosed with hypertension?

3 :
The nurse is assessing a client who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider?

4 :
The nurse is reviewing the laboratory test results for a client who has recently been diagnosed with hypertension. Which result is most important to communicate to the health care provider?

5 :
The nurse on the intermediate care unit received a change-of-shift report on four patients with hypertension. Which patient should the nurse assess first?

6 :
Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown origin?

7 :
A patient is apneic and has no palpable pulses. The heart monitor shows sinus tachycardia, rate 132. What action should the nurse take next?

8 :
While assessing an older adult client, the nurse notes jugular venous distention (JVD) with the head of the client's bed elevated 45 degrees. What does this finding indicate?

9 :
A patient with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. What topic should the nurse plan to include in patient teaching?

10 :
After the nurse gives IV atropine to a patient with symptomatic type 1. second-degree atrioventricular (AV) block, which finding indicates that the drug has been effective?

Connect With Us

Medsurg-390

No.

1 : Which information is most important for the nurse to include when teaching a client newly diagnosed with hypertension?

3 : The nurse is assessing a client who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider?

4 : The nurse is reviewing the laboratory test results for a client who has recently been diagnosed with hypertension. Which result is most important to communicate to the health care provider?

5 : The nurse on the intermediate care unit received a change-of-shift report on four patients with hypertension. Which patient should the nurse assess first?

6 : Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown origin?

7 : A patient is apneic and has no palpable pulses. The heart monitor shows sinus tachycardia, rate 132. What action should the nurse take next?

8 : While assessing an older adult client, the nurse notes jugular venous distention (JVD) with the head of the client's bed elevated 45 degrees. What does this finding indicate?

9 : A patient with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. What topic should the nurse plan to include in patient teaching?

10 : After the nurse gives IV atropine to a patient with symptomatic type 1. second-degree atrioventricular (AV) block, which finding indicates that the drug has been effective?

1 :
Which information is most important for the nurse to include when teaching a client newly diagnosed with hypertension?

3 :
The nurse is assessing a client who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider?

4 :
The nurse is reviewing the laboratory test results for a client who has recently been diagnosed with hypertension. Which result is most important to communicate to the health care provider?

5 :
The nurse on the intermediate care unit received a change-of-shift report on four patients with hypertension. Which patient should the nurse assess first?

6 :
Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown origin?

7 :
A patient is apneic and has no palpable pulses. The heart monitor shows sinus tachycardia, rate 132. What action should the nurse take next?

8 :
While assessing an older adult client, the nurse notes jugular venous distention (JVD) with the head of the client's bed elevated 45 degrees. What does this finding indicate?

9 :
A patient with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. What topic should the nurse plan to include in patient teaching?

10 :
After the nurse gives IV atropine to a patient with symptomatic type 1. second-degree atrioventricular (AV) block, which finding indicates that the drug has been effective?