Hypertensive Crisis

Question 1

A nurse is caring for a patient admitted to the health care facility with acute ischemic stroke. The patient is receiving IV antihypertensive drugs. Which interventions should the nurse perform for this patient? Select all that apply.
1 Assess blood pressure (BP) and pulse every 30 minutes.
2 Titrate drug according to mean arterial pressure (MAP) or BP as prescribed.
3 Measure hourly urine output.
4 Provide assistance to get up as patient desires.
5 Perform frequent neurologic checks

Answer 1

ANS: 2,3,5
Drugs should be titrated according to MAP or BP as prescribed. The nurse should measure hourly urine output to assess renal perfusion and should perform frequent neurologic checks. Antihypertensive IV drugs have a rapid onset of action; hence BP and pulse should be assessed every two to three minutes using a noninvasive BP machine. The patient should be restricted to bed; severe cerebral ischemia or fainting may result if the patient tries to get up.