Lewis Ch 32: Hypertension

Question 1

Which action should the nurse in the hypertension clinic take to obtain an accurate baseline blood pressure (BP) for a new patient?

a. Deflate the BP cuff at a rate of 5 to 10 mm Hg per second.
b. Have the patient sit in a chair with the feet flat on the floor.
c. Assist the patient to the supine position for BP measurements.
d. Obtain two BP readings in the dominant arm and average the results.

Answer 1

ANS: B
The patient should be seated with the feet flat on the floor. The BP is obtained in both arms, and the results of the two arms are not averaged. The patient does not need to be in the supine position. The cuff should be deflated at 2 to 3 mm Hg per second.

Question 2

The nurse obtains the following information from a patient newly diagnosed with elevated blood pressure. Which finding is most important to address with the patient?

a. Low dietary fiber intake
b. No regular physical exercise
c. Drinks a beer with dinner every night
d. Weight is 5 pounds above ideal weight

Answer 2

ANS: B
The recommendations for preventing hypertension include exercising aerobically for 30 minutes most days of the week. A weight that is 5 pounds over the ideal body weight is not a risk factor for hypertension. The Dietary Approaches to Stop Hypertension (DASH) diet is high in fiber but increasing fiber alone will not prevent hypertension from developing. The patient’s alcohol intake is within guidelines and will not increase the hypertension risk.

Question 3

Which action should the nurse take when giving the first dose of oral labetalol to a patient with hypertension?

a. Encourage the use of hard candy to prevent dry mouth.
b. Teach the patient that headaches often occur with this drug.
c. Instruct the patient to call for help if heart palpitations occur.
d. Ask the patient to request assistance before getting out of bed.

Answer 3

ANS: D
Labetalol decreases sympathetic nervous system activity by blocking both a- and b-adrenergic receptors, leading to vasodilation and a decrease in heart rate, which can cause severe orthostatic hypotension. Heart palpitations, dry mouth, dehydration, and headaches are possible side effects of other antihypertensives.

Question 4

After the nurse teaches the patient with stage 1 hypertension about diet modifications, which diet choice indicates that the teaching has been most effective?

a. The patient avoids eating nuts or nut butters.
b. The patient restricts intake of chicken and fish.
c. The patient drinks low-fat milk with each meal.
d. The patient has two cups of coffee in the morning.

Answer 4

ANS: C
For the prevention of hypertension, the Dietary Approaches to Stop Hypertension (DASH) recommendations include increasing the intake of calcium-rich foods. Caffeine restriction and decreased protein intake are not part of the recommendations. Nuts are high in beneficial nutrients and 4 to 5 servings weekly are recommended in the DASH diet.

Question 5

A patient diagnosed with hypertension has been prescribed captopril. Which information is most important to teach the patient about this drug?

a. Include high-potassium foods such as bananas in the diet.
b. Increase fluid intake if dryness of the mouth is a problem.
c. Change position slowly to help prevent dizziness and falls.
d. Check the blood pressure in both arms before taking the drug.

Answer 5

ANS: C
The angiotensin-converting enzyme (ACE) inhibitors often cause orthostatic hypotension, and patients should be taught to change position slowly to allow the vascular system time to compensate for the position change. Increasing fluid intake may counteract the effect of the drug. The patient is taught to use gum or hard candy to relieve dry mouth. The BP should be taken in the nondominant arm by newly diagnosed patients in the morning, before taking the drug, and in the evening. Because ACE inhibitors cause potassium retention, increased intake of high-potassium foods is inappropriate.

Question 6

Propranolol (Inderal) is prescribed for a patient diagnosed with hypertension. The nurse should consult with the health care provider before giving this drug when the patient reveals a history of:

a. asthma.
b. daily alcohol use.
c. peptic ulcer disease.
d. myocardial infarction (MI).

Answer 6

ANS: A
Nonselective b-blockers block b1- and b2-adrenergic receptors and can cause bronchospasm, especially in patients with a history of asthma. b-Blockers will have no effect on the patient’s peptic ulcer disease or alcohol use. b-Blocker therapy is recommended after MI.

Question 7

A 62-yr-old patient who has no history of hypertension or other health problems suddenly develops a blood pressure (BP) of 198/110 mm Hg. After reconfirming the BP, it is appropriate for the nurse to tell the patient that:

a. a BP recheck should be scheduled in a few weeks.
b. dietary sodium and fat content should be decreased.
c. diagnosis, treatment, and monitoring will be needed.
d. there is danger of a stroke, requiring hospitalization.

Answer 7

ANS: C
A sudden increase in BP in a patient older than age 50 years with no hypertension history or risk factors indicates that the hypertension may be secondary to some other problem. The BP will need treatment and ongoing monitoring. If the patient has no other risk factors, a stroke in the immediate future is unlikely. There is no indication that dietary salt or fat intake have contributed to this sudden increase in BP. Reducing intake of salt and fat alone will not be adequate to reduce this BP to an acceptable level.

Question 8

Which action will be included in the plan of care for a patient who is receiving nicardipine (Cardene) to treat a hypertensive emergency?

a. Keep the patient NPO to prevent aspiration caused by nausea and possible vomiting.
b. Organize nursing activities so that the patient has 8 hours of undisturbed sleep at night.
c. Assist the patient up in the chair for meals to avoid complications associated with immobility.
d. Use an automated noninvasive blood pressure machine to obtain frequent measurements.

Answer 8

ANS: D
Frequent monitoring of BP is needed when the patient is receiving rapid-acting IV antihypertensive medications. This can be most easily accomplished with an automated BP machine or arterial line. The patient will require frequent assessments, so allowing 8 hours of undisturbed sleep is not reasonable. When patients are receiving IV vasodilators, bed rest is maintained to prevent decreased cerebral perfusion and fainting. There is no indication that this patient is nauseated or at risk for aspiration, so an NPO status is unnecessary.

Question 9

The nurse has just finished teaching a hypertensive patient about a newly prescribed drug, ramipril (Altace). Which patient statement indicates that more teaching is needed?

a. “The medication may not work well if I take aspirin.”
b. “I can expect some swelling around my lips and face.”
c. “The doctor may order a blood potassium level occasionally.”
d. “I will call the doctor if I notice that I have a frequent cough.”

Answer 9

ANS: B
Angioedema occurring with angiotensin-converting enzyme (ACE) inhibitor therapy is an indication that the ACE inhibitor should be discontinued. The patient should be taught that if any swelling of the face or oral mucosa occurs, the health care provider should be immediately notified because this could be life threatening. The other patient statements indicate that the patient has an accurate understanding of ACE inhibitor therapy.

Question 10

During change-of-shift report, the nurse obtains the following information about a hypertensive patient who received the first dose of nadolol (Corgard) during the previous shift. Which information indicates that the patient needs immediate intervention?

a. The patient’s pulse has dropped from 68 to 57 beats/min.
b. The patient reports that the fingers and toes feel quite cold.
c. The patient has developed wheezes throughout the lung fields.
d. The patient’s blood pressure (BP) reading is now 158/92 mm Hg.

Answer 10

ANS: C
The most urgent concern for this patient is the wheezes, which indicate that bronchospasm (a common adverse effect of the noncardioselective -blockers) is occurring. The nurse should immediately obtain an O2 saturation measurement, apply supplemental O2, and notify the health care provider. The mild decrease in heart rate and cold fingers and toes are associated with -receptor blockade but do not require any change in therapy. The BP reading may indicate that a change in medication type or dose may be indicated. However, this is not as urgently needed as addressing the bronchospasm.

Question 11

An older patient has been diagnosed with possible white coat hypertension. Which planned action by the nurse addresses that suspected cause of the hypertension?

a. Instruct the patient about the need to decrease stress levels.
b. Teach the patient how to self-monitor and record BPs at home.
c. Tell the patient and caregiver that major dietary changes are needed.
d. Schedule the patient for regular blood pressure (BP) checks in the clinic.

Answer 11

ANS: B
In the phenomenon of “white coat” hypertension, patients have elevated BP readings in a clinical setting and normal readings when BP is measured elsewhere. Having the patient self-monitor BPs at home will provide a reliable indication about whether the patient has hypertension. Regular BP checks in the clinic are likely to be high in a patient with white coat hypertension. There is no evidence that this patient has elevated stress levels or a poor diet, and those factors do not cause white coat hypertension.

Question 12

Which blood pressure (BP) finding by the nurse indicates that no changes in therapy are needed for a 48-yr-old patient with newly diagnosed hypertension?

a. 98/56 mm Hg
b. 128/76 mm Hg
c. 128/92 mm Hg
d. 142/78 mm Hg

Answer 12

ANS: B
The 8th Joint National Committee’s recommended goal for antihypertensive therapy for a 30- to 59-yr-old patient with hypertension is a BP below 130/80 mm Hg. The BP of 98/56 mm Hg may indicate overtreatment of the hypertension and an increased risk for adverse drug effects. The other two blood pressures indicate a need for modifications in the patient’s treatment.

Question 13

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

a. Most people are able to control BP through dietary changes.
b. Annual BP checks are needed to monitor treatment effectiveness.
c. Hypertension is usually asymptomatic until target organ damage occurs.
d. Increasing physical activity controls blood pressure (BP) for most people.

Answer 13

ANS: C
Hypertension is usually asymptomatic until target organ damage has occurred. Lifestyle changes (e.g., physical activity, dietary changes) are used to help manage BP, but drugs are needed for most patients. Home BP monitoring should be taught to the patient and findings checked by the health care provider frequently when starting treatment for hypertension and then every 3 months when stable.

Question 14

The nurse on the intermediate care unit received change-of-shift report on four patients with hypertension. Which patient should the nurse assess first?
a. 48-yr-old with a blood pressure of 160/92 mm Hg who reports chest pain
b. 52-yr-old with a blood pressure of 198/90 mm Hg who has intermittent
claudication
c. 50-yr-old with a blood pressure of 190/104 mm Hg who has a creatinine of 1.7
mg/dL
d. 43-yr-old with a blood pressure of 172/98 mm Hg whose urine shows
microalbuminuria.

Answer 14

ANS: A
The patient with chest pain may be experiencing acute myocardial infarction and rapid assessment and intervention are needed. Intermittent claudication, elevated creatinine, and microalbuminuria show target organ damage but do not indicate acute processes.

Question 15

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

a. Serum creatinine of 2.8 mg/dL
b. Serum potassium of 4.5 mEq/L
c. Serum hemoglobin of 14.7 g/dL
d. Blood glucose level of 96 mg/dL

Answer 15

ANS: A
The elevated serum creatinine indicates renal damage caused by the hypertension. The other laboratory results are normal.

Question 16

A patient with a history of hypertension treated with a diuretic and an angiotensin-converting enzyme (ACE) inhibitor arrives in the emergency department. The patient reports a severe headache and nausea and has a blood pressure (BP) of 238/118 mm Hg. Which question should the nurse ask to follow up on these findings?

a. “Have you recently taken any antihistamines?”
b. “Have you consistently taken your medications?”
c. “Did you take any acetaminophen (Tylenol) today?”
d. “Have there been recent stressful events in your life?”

Answer 16

ANS: B
Sudden withdrawal of antihypertensive medications can cause rebound hypertension and hypertensive crisis. Although many over-the-counter medications can cause hypertension, antihistamines and acetaminophen do not increase BP. Stressful events will increase BP but not usually to the level seen in this patient.

Question 17

The nurse is assessing a patient 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?

a. Urine output over 8 hours is 250 mL less than the fluid intake.
b. The patient cannot move the left arm and leg when asked to do so.
c. Tremors are noted in the fingers when the patient extends the arms.
d. The patient reports a headache with pain at level 7 of 10 (0 to 10 scale).

Answer 17

ANS: B
The patient’s inability to move the left arm and leg indicates that a stroke may be occurring and will require immediate action to prevent further neurologic damage. The other clinical manifestations are also likely caused by the hypertension and will require rapid nursing actions, but they do not require action as urgently as the neurologic changes.

Question 18

A patient with hypertension who has just started taking atenolol (Tenormin) returns to the health clinic after 2 weeks for a follow-up visit. The blood pressure (BP) is unchanged from the previous visit. Which action should the nurse take first?

a. Tell the patient why a change in drug dosage is needed.
b. Ask the patient if the medication is being taken as prescribed.
c. Review with the patient any lifestyle changes made to help control BP.
d. Teach the patient that multiple drugs are often needed to treat hypertension.

Answer 18

ANS: B
Because nonadherence with antihypertensive therapy is common, the nurse’s initial action should be to determine whether the patient is taking the atenolol as prescribed. The other actions also may be implemented, but these would be done after assessing patient adherence with the prescribed therapy.

Question 19

The registered nurse (RN) is caring for a patient with a hypertensive crisis who is receiving sodium nitroprusside. Which nursing action can the nurse delegate to an experienced licensed practical/vocational nurse (LPN/VN)?

a. Evaluate effectiveness of nitroprusside therapy on blood pressure (BP).
b. Assess the patient’s environment for adverse stimuli that might increase BP.
c. Titrate nitroprusside to decrease mean arterial pressure (MAP) to 115 mm Hg.
d. Set up the automatic noninvasive BP machine to take readings every 15 minutes.

Answer 19

ANS: D
LPN/VN education and scope of practice include the correct use of common equipment such as automatic noninvasive blood pressure machines. Assessment, evaluation, and medication titration require advanced nursing judgment and education, and should be done by RNs.

Question 20

The charge nurse observes a new registered nurse (RN) doing discharge teaching for a patient with hypertension who has a new prescription for enalapril (Vasotec). Which statement by the new nurse to the patient would require the charge nurse’s intervention?

a. “Make an appointment with the dietitian for teaching.”
b. “Increase your dietary intake of high-potassium foods.”
c. “Check your blood pressure at home at least once a day.”
d. “Move slowly when moving from lying to sitting to standing.”

Answer 20

ANS: B
The ACE inhibitors cause retention of potassium by the kidney, so hyperkalemia is a possible adverse effect. The other teaching by the new RN is appropriate for a patient with newly diagnosed hypertension who has just started therapy with enalapril.

Question 21

Which assessment finding for a patient receiving IV furosemide (Lasix) to treat stage 2 hypertension is most important to report to the health care provider?

a. Blood glucose level of 175 mg/dL
b. Serum potassium level of 3.0 mEq/L
c. Orthostatic systolic BP decrease of 12 mm Hg
d. Current blood pressure (BP) reading of 168/94 mm Hg

Answer 21

ANS: B
Hypokalemia is a frequent adverse effect of the loop diuretics and can cause life-threatening dysrhythmias. The health care provider should be notified of the potassium level immediately and administration of potassium supplements initiated. The elevated blood glucose and BP also need collaborative intervention but will not require action as urgently as the hypokalemia. An orthostatic drop of 12 mm Hg will require intervention only if the patient is symptomatic.

Question 22

Which action should the nurse take first to assist a patient with newly diagnosed stage 1 hypertension in making needed dietary changes?

a. Collect a detailed diet history.
b. Provide a list of low-sodium foods.
c. Help the patient make an appointment with a dietitian.
d. Teach the patient about foods that are high in potassium.

Answer 22

ANS: A
The initial nursing action should be assessment of the patient’s baseline dietary intake through a thorough diet history. The other actions may be appropriate, but assessment of the patient’s baseline should occur first.

Question 23

The nurse is caring for a 70-yr-old patient who takes hydrochlorothiazide and enalapril (Norvasc). The patient’s blood pressure (BP) continues to be high. Which patient information may indicate a need for a change?

a. Patient takes a daily multivitamin tablet.
b. Patient uses ibuprofen to treat osteoarthritis.
c. Patient checks BP daily just after getting up.
d. Patient drinks wine three to four times a week.

Answer 23

ANS: B
Because use of nonsteroidal antiinflammatory drugs (NSAIDs) can prevent adequate BP control, the patient may need to avoid the use of ibuprofen. A multivitamin tablet will help supply vitamin D, which may help lower BP. BP decreases while sleeping, so self-monitoring early in the morning will result in obtaining pressures that are at their lowest. The patient’s alcohol intake is not excessive.