Question

The nurse is assessing a client with a hypertensive emergency. Which ﬁnding is most important to report to the health care provider?

Answer 1

Correct Answers:

The client has a new-onset blurry vision and facial asymmetry

Rationale :

🔷 End‑organ damage: Hypertensive emergency is defined by severe BP elevation with acute target‑organ injury; focal neurological deficits/visual changes signal cerebrovascular involvement and demand immediate escalation.

🔷 Stroke concern: Facial asymmetry and blurry vision align with FAST signs (face droop, arm weakness, speech), raising suspicion for acute stroke requiring rapid evaluation and BP control.

🔷 Treatment priority: Presence of neurologic deficits shifts priority from routine symptom treatment to urgent IV antihypertensives and neuroimaging to prevent progression.

🔷 Compare other findings: A headache or mild epistaxis can accompany hypertension, but they do not outweigh focal deficits in urgency.

🔷 Renal output context: 30 mL/hr (120 mL/4 hr) is borderline but not immediately life‑threatening compared with new focal neuro deficits.

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Answer 2

Correct Answers:

Anticipate a prescription for clopidogrel and simvastatin

Rationale :

💎 ABI meaning: ABI 0.89 indicates mild PAD (≤0.90), prompting medical therapy and risk‑reduction rather than labeling as normal or jumping to surgery.

💎 Antiplatelet: Clopidogrel reduces atherothrombotic events by limiting platelet aggregation—core therapy in PAD to lower CV events.

💎 Statin: Simvastatin (or another high‑intensity statin as appropriate) stabilizes plaques and lowers LDL, reducing MI/stroke risk in PAD.

💎 Compression caution: Routine compression stockings are for venous disease; they can worsen ischemia in untreated arterial disease.

💎 Next steps: Combine meds with smoking cessation, walking program, BP/DM control to improve symptoms and outcomes.

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Answer 3

Correct Answers:

"Have you consistently taken your medications?"

Rationale :

✳️ Most common cause: Hypertensive urgency/emergency frequently stems from missed antihypertensives; verifying adherence is the most actionable first step.

✳️ Guides management: Nonadherence confirms need for reinstitution/adjustment of therapy and targeted education.

✳️ Less relevant triggers: OTC antihistamines/acetaminophen are not typical drivers of severe BP to 210/106.

✳️ Stress contribution: While stress can raise BP, it’s secondary to the central question of consistent medication use.

✳️ Safety & teaching: Identifying lapses enables barrier assessment (access, side‑effects) to prevent recurrence

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Answer 4

Correct Answers:

Notify the surgeon and anesthesiologist

Rationale :

❖ Limb‑threatening: After AAA repair, absent distal pulses with a cool, mottled leg indicates acute arterial occlusion/graft compromise—a surgical emergency.

❖ No delays: Immediate notification is critical; delaying to warm or recheck later risks irreversible ischemia.

❖ Baseline can follow: Comparing to pre‑op pulses is useful after calling—time = tissue in acute ischemia.

❖ Assessment focus: Monitor color, temperature, cap refill, motor/sensory while preparing for urgent intervention.

❖ Likely next steps: Expect OR return, thrombectomy, or graft revision; rapid action preserves limb viability.

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Answer 5

Correct Answers:

A client with a blood pressure of 190/92 mm Hg who reports chest pain

Rationale :

🔶 Possible MI/dissection: Chest pain with severe hypertension suggests acute coronary syndrome or aortic catastrophe, both time‑critical.

🔶 Symptom risk: Symptomatic patients take priority over asymptomatic elevated BPs.

🔶 Immediate actions: Obtain ECG, troponin, VS, treat pain, and initiate IV antihypertensive if indicated.

🔶 Other options: Tachycardia alone or scheduled testing lack red‑flag symptoms.

🔶 Outcome impact: Early intervention reduces myocardial damage/mortality.

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Answer 6

Correct Answers:

Pain level of 10 out of 10
Temperature 101.9 F
Hemoglobin: 7g/dl
Cocaine abuse

Rationale :

🔹 Pain Severe pain triggers sympathetic activation, raising HR markedly.

🔹 Fever Pyrexia (101.9 °F) increases metabolic demand, producing sinus tachycardia.

🔹 Anemia Hgb 7 g/dL lowers oxygen‑carrying capacity; HR rises to maintain DO₂.

🔹 Stimulants Cocaine increases catecholamines, commonly causing tachyarrhythmias.

🔹 Normal glucose 90 mg/dL is normal and not a tachycardia driver.

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Answer 7

Correct Answers:

cardiac catheterization

Rationale :

⭐ ST‑segment elevation during stress suggests acute transmural ischemia (STEMI‑equivalent).

⭐ Definitive therapy: Emergent coronary angiography/PCI is the standard to reperfuse jeopardized myocardium.

⭐ Other tests: TEE, telemetry, or switching to pharmacologic stress do not treat acute ST elevation.

⭐ Time‑sensitive: Faster door‑to‑balloon improves outcomes; prep for cath lab without delay.

⭐ Nursing role: Activate cath lab, keep NPO, secure IV access, and obtain consent if possible.

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Answer 8

Correct Answers:

Assess pulse of affected extremity every 15 minutes at ﬁrst.

Rationale :

◆ Graft patency: After fem‑pop bypass, frequent neurovascular checks (color, temp, pulses q15min) detect early occlusion.

◆ Compartment syndrome: Monitor for pain/pallor/paresthesia/paralysis/pressure, but primary immediate frequency is pulse checks q15min in the first hours.

◆ Pain palpation: Excess palpation may compromise comfort and isn’t as sensitive as pulse trends for graft failure.

◆ Doppler schedule: Once daily is inadequate early post‑op when hourly/quarter‑hourly checks are standard.

◆ Outcome: Prompt detection enables timely re‑intervention and limb salvage.

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Answer 9

Correct Answers:

Use an automated noninvasive blood pressure machine to obtain frequent measurements.

Rationale :

✔️ Tight control: In hypertensive emergency, BP should be reduced carefully with frequent measurements (q5–15 min).

✔️ Safety with nifedipine: If nifedipine is being used, close BP monitoring is essential to avoid excessive drops and organ hypoperfusion.

✔️ Priorities: Continuous reassessment outweighs sleep consolidation or early chair sitting.

✔️ Aspiration: Routine NPO isn’t indicated solely for BP management; monitoring is the key nursing action.

✔️ Escalation: Consider arterial line if available/ordered; otherwise automated NIBP at frequent intervals is appropriate.

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Answer 10

Correct Answers:

“I don't have any abdominal pain or any type of problems."

Rationale :

🔷 Often asymptomatic: Most abdominal aortic aneurysms (AAAs) are silent until large or ruptured, so clients frequently deny abdominal discomfort.

🔷 Incidental finding: Many AAAs are detected incidentally during imaging for unrelated issues.

🔷 Symptom onset: Pain usually develops only with rapid expansion or impending rupture.

🔷 Location: Typical AAA pain, if present, is steady, deep, and located in the abdomen, back, or flank, not related to meals.

🔷 Risk: Asymptomatic presentation emphasizes the importance of screening in high-risk populations (age, smoking, family history).

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Medical-Surgical Exam 3

No.

1 :
The nurse is assessing a client with a hypertensive emergency. Which ﬁnding is most important to report to the health care provider?

2 :
The nurse is assessing a client with a presumptive diagnosis of peripheral arterial disease. The nurse obtains an Ankle-Brachial index of 0.89. Which intervention should the nurse take next?

3 :
A nurse is assessing a client with a history of high blood pressure. The client's blood pressure is 210/106 mm Hg during the assessment. What follow-up question should the nurse ask?

4 :
The nurse is caring for a client immediately after repair of an abdominal aortic aneurysm. On assessment, the client has absent popliteal, posterior tibial, and dorsalis pedis pulses. The leg cool and mottled. Which action should the nurse take ﬁrst?

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

6 :
The nurse is assessing a client with a heart rate of 124 bpm. What clinical ﬁnding(s) should the nurse assess as causes of tachycardia? Select all that apply.

7 :
A nurse accompanies a client to an exercise stress test. The client can achieve the target heart rate, but the electrocardiogram indicates ST-segment elevation. Which procedure will the nurse prepare the patient for?

8 :
A client who has undergone a femoral to popliteal bypass graft surgery returns to the surgical unit. Which assessments should the nurse perform during the ﬁrst postoperative day?

9 :
The nurse is caring for a client in a hypertensive emergency. Which action will be included in the plan of care during hypertensive emergency who is receiving nifedipine?

10 :
The client is diagnosed with an abdominal aortic aneurysm. Which statement would the nurse expect the client to make during the admission assessment?

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Medical-Surgical Exam 3

No.

1 : The nurse is assessing a client with a hypertensive emergency. Which ﬁnding is most important to report to the health care provider?

2 : The nurse is assessing a client with a presumptive diagnosis of peripheral arterial disease. The nurse obtains an Ankle-Brachial index of 0.89. Which intervention should the nurse take next?

3 : A nurse is assessing a client with a history of high blood pressure. The client's blood pressure is 210/106 mm Hg during the assessment. What follow-up question should the nurse ask?

4 : The nurse is caring for a client immediately after repair of an abdominal aortic aneurysm. On assessment, the client has absent popliteal, posterior tibial, and dorsalis pedis pulses. The leg cool and mottled. Which action should the nurse take ﬁrst?

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

6 : The nurse is assessing a client with a heart rate of 124 bpm. What clinical ﬁnding(s) should the nurse assess as causes of tachycardia? Select all that apply.

7 : A nurse accompanies a client to an exercise stress test. The client can achieve the target heart rate, but the electrocardiogram indicates ST-segment elevation. Which procedure will the nurse prepare the patient for?

8 : A client who has undergone a femoral to popliteal bypass graft surgery returns to the surgical unit. Which assessments should the nurse perform during the ﬁrst postoperative day?

9 : The nurse is caring for a client in a hypertensive emergency. Which action will be included in the plan of care during hypertensive emergency who is receiving nifedipine?

10 : The client is diagnosed with an abdominal aortic aneurysm. Which statement would the nurse expect the client to make during the admission assessment?

1 :
The nurse is assessing a client with a hypertensive emergency. Which ﬁnding is most important to report to the health care provider?

2 :
The nurse is assessing a client with a presumptive diagnosis of peripheral arterial disease. The nurse obtains an Ankle-Brachial index of 0.89. Which intervention should the nurse take next?

3 :
A nurse is assessing a client with a history of high blood pressure. The client's blood pressure is 210/106 mm Hg during the assessment. What follow-up question should the nurse ask?

4 :
The nurse is caring for a client immediately after repair of an abdominal aortic aneurysm. On assessment, the client has absent popliteal, posterior tibial, and dorsalis pedis pulses. The leg cool and mottled. Which action should the nurse take ﬁrst?

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

6 :
The nurse is assessing a client with a heart rate of 124 bpm. What clinical ﬁnding(s) should the nurse assess as causes of tachycardia? Select all that apply.

7 :
A nurse accompanies a client to an exercise stress test. The client can achieve the target heart rate, but the electrocardiogram indicates ST-segment elevation. Which procedure will the nurse prepare the patient for?

8 :
A client who has undergone a femoral to popliteal bypass graft surgery returns to the surgical unit. Which assessments should the nurse perform during the ﬁrst postoperative day?

9 :
The nurse is caring for a client in a hypertensive emergency. Which action will be included in the plan of care during hypertensive emergency who is receiving nifedipine?

10 :
The client is diagnosed with an abdominal aortic aneurysm. Which statement would the nurse expect the client to make during the admission assessment?