Study Guide Chapter 32 Hypertension

Question 1

A patient is given an alpha 1 adrenergic agonist and experiences a reflex bradycardia. What normal mechanism of BP control is stimulated in this situation?

Answer 1

The vasoconstriction caused by the alpha 1 adrenergic agent raises the BP , stimulating the baroreceptors. The baroreceptors send impulses to the sympathetic vasomotor center in the brainstem, which inhibit the SNS, resulting in a decreased HR , decreased force of contraction and vasodilation.

Question 2

A patient uses a mixed B-adrenergic blocking agent for tx of migraine HA. What effect might this drug have on BP and why?

Answer 2

Lower BP because of decreased stroke volume and decreased HR , both of which decrease CO.

Question 3

Risk factors for primary HTN that are not related to lifestyle behaviors.

Answer 3

Age, Ethnicity, Family, Gender, genetic link

Rational: HTN progresses with increasing age. It is more prevalent in men before early middle age and above the age of 64 in women. African Americans have a higher incidence of HTN than do whites. Children and siblings of patients with HTN should be screened and taught about healthy lifestyles

Question 4

The patient diagnosed with secondary HTN asks why it is called secondary and not primary. What is the best explanation for the nurse to provide?

a. Has a more gradual onset than primary HTN
b. Does not cause the target organ damage that occurs with primary HTN
c. Has a specific cause, such as renal disease, that often can be treated by medicine or surgery
d. Is caused by age-related changes in BP regulatory mechanisms in people over 65 years of age

Answer 4

c. Has a specific cause, such as renal disease, that often can be treated by medicine or surgery

Rational: Secondary HTN has an underlying cause that can often be treated, in contrast to primary or essential HTN, which has no single known cause. Isolated systolic HTN occurs when the systolic BP is consistenly elevated over 140 mm Hg, but the diastolic BP remains at 90 mm Hg or more, which is more prevalent in older adults. The only type of HTN that does not cause target organ damage is pseudoHTN.

Question 5

What early manifestations is the patient with primary hypertension likely to report?

a. No symptoms
b. Cardiac palpitations
c. Dyspnea on exertion
d. Dizziness and vertigo

Answer 5

a. No symptoms

Rational: HTN is often asymptomatic, especially if it is mild or moderate, and has been called the “silent killer”. The absence of symptoms often leads to noncompliance with medical treatment and a lack of concern about the disease in patients. With severe HTN, symptoms may include fatigue, palpitations, angina, dyspnea, and dizziness

Question 6

Most organ damage in hypertension is related to what?

a. Increased fluid pressure against organ tissue
b. Atherosclerotic changes in vessels that supply the organs
c. Erosion and thinning of blood vessels in organs from constant pressure
d. Increased hydrostatic pressure causing leakage of plasma into organ interstitial spaces

Answer 6

b. Atherosclerotic changes in vessels that supply the organs

Rational: Elevated BP causes endothelial damage, which causes the inner lining of arterioles to become thickened and stiffened and affects coronary circulation, cerebral circulation, peripheral vessels, and renal and retinal blood vessels. The narrowed vessels lead to ischemia and ultimately to damage of these vessels

Question 7

The patient who is being admitted has had a history of uncontrolled hypertension. High SVR is most likely to cause damage to which organ?

a. Brain
b. Heart
c. Retina
d. Kidney

Answer 7

b. Heart

Rational: The increased systemic vascular resistance (SVR) of hypertension directly increases the workload of the heart, and heart failure occurs when the heart can no longer pump effectively against the increased resistance. The heart may be indirectly damaged by atherosclerotic changes in the blood vessels, as are the brain, retina, and kidney.

Question 8

Identify the significance of the following laboratory study results when found in patients with hypertension.
- Blood urea nitrogen (BUN): 48 mg/dL (17.1 mmol/L), Creatinine: 4.3 mg/dL (380 mmol/L)

Answer 8

Elevated BUN and creatinine may indicate destruction of glomeruli and tubules of the kidney resulting from HTN

Question 9

Identify the significance of the following laboratory study results when found in patients with hypertension.
- Serum K+: 3.1 mEq/L (3.1 mmol/L)

Answer 9

Serum potassium levels are decreased when HTN is associated with hyperaldosteronism

Question 10

Identify the significance of the following laboratory study results when found in patients with hypertension.
- Serum uric acid: 9.2 mg/L (547 mmol/L)

Answer 10

An increased uric acid level may be caused by diuretics used to treat hypertension

Question 11

Identify the significance of the following laboratory study results when found in patients with hypertension.
- Fasting blood glucose: 183 mg/dL (10.2 mmol/L)

Answer 11

Fasting glucose levels are elevated when HTN is associated with glucose intolerance and insulin resistance

Question 12

Identify the significance of the following laboratory study results when found in patients with hypertension.
- Low-density lipoproteins (LDL): 154 mg/dL (4.0 mmol/L)

Answer 12

An elevated LDL level indicates an increased risk for atherosclerotic changes in the patient with HTN

Question 13

A 42-year-old man has been diagnosed with primary hypertension with an average BP of 162/92 mm Hg on three consecutive clinic visits. What are four priority lifestyle modifications that should be explored in the initial treatment of the patient?

Answer 13

1) Dietary modifications to increase fruits, vegetables, fat-free milk, whole grains, fish, poultry, beans, seeds, and nuts; and restrict sodium, cholesterol, and saturated fat; maintain intake of potassium, calcium, vitamin D, and omega-3 fatty acids; and promote weight reduction if overweight
2) Daily moderate-intensity physical activity for at least 30 minutes on most days of the week
3) Cessation of tobacco use (if a user)
4) Moderation or cessation of alcohol intake
- Usually medications, monitoring BP at home, and psychosocial risk factors must also be addressed.

Question 14

What is the primary BP effect of β-adrenergic blockers such as atenolol (Tenormin)?

a. Vasodilation of arterioles by blocking movement of calcium into cells
b. Decrease Na+ and water reabsorption by blocking the effect of aldosterone
c. Decrease CO by decreasing rate and strength of the heart and renin secretion by the kidneys
d. Vasodilation caused by inhibiting sympathetic outflow from the central nervous system (CNS)

Answer 14

c. Decrease CO by decreasing rate and strength of the heart and renin secretion by the kidneys

Rational: Cardioselective B-adrenergic blockers decrease CO, reduce sympathetic vasoconstrictor tone, and decrease renin secretion by kidneys. Calcium channel blockers reduce BP by causing blocked movement of calcium into cells, which causes vasodilation of arterioles. Spironolactone blocks the effect of aldosterone. Central adrenergic antagonists such as clonidine (Catapres) inhibit sympathetic outflow from the central nervous system (CNS)

Question 15

The patient asks the nurse about valsartan (Diovan), the new medication prescribed for blood pressure. What is the best explanation the nurse can use to explain the action of this medication?

a. Prevents the conversion of angiotensin I to angiotensin II
b. Acts directly on smooth muscle of arterioles to cause vasodilation
c. Decreases extracellular fluid volume by increasing Na and Cl excretion with water
d. Vasodilation, prevents the action of angiotensin II, and promotes increased salt and water excretion

Answer 15

d. Vasodilation, prevents the action of angiotensin II, and promotes increased salt and water excretion

Rational: Valsatan (Diovan) is an angiotensin II receptor blocker (ARB). ARBs prevent the action of angiotensin II, produce vasodilation, and increase salt and water excretion. Angiotensin-converting enzyme (ACE) inhibitors prevent the conversion of angiotensin I to angiotensin II. Direct vasodilators act directly on smooth muscle of arterioles to cause vasodilation. Thiazide diuretics decrease extracellular fluid volume by increasing Na and Cl excretion with water

Question 16

Dietary teaching that includes eating dietary sources of potassium is indicated for the hypertensive patient taking which drug?

a. Enalapril
b. Labetalol
c. Spironolactone
d. Hydrochlorothiazide

Answer 16

d. Hydrochlorothiazide

Rational: Hydochlorothiazide is a thiazide diuretic that causes sodium and potassium loss through the kidneys. High potassium foods should be included in the diet, or potassium supplements may be used to prevent hypokalemia. Enalapril and spirnolactone may cause hyperkalemia by inhibiting the action of aldosterone, and potassium supplements should NOT be used by patients taking these drugs. As a combined alpha/beta blocker, labetalol does not affect potassium levels.

Question 17

A patient with stage 2 hypertension who is taking chlorothiazide (Diuril) and lisinopril (Zestril) has prazosin (Minipress) added to the medication regimen. What is most important for the nurse
to teach the patient to do?
a. Weigh every morning to monitor for fluid retention
b. Change position slowly and avoid prolonged standing
c. Use sugarless gum or candy to help relieve dry mouth
d. Take the pulse daily to note any slowing of the heart rate

Answer 17

b. Change position slowly and avoid prolonged standing

Rational: Chlorothiazide is a thiazide diuretic that causes orthostatic hypotension. Prazosin is an alpha-adrenergic blocker that causes dilation of arterioles and veins and causes orthostatic hypotension. The patient may feel dizzy, weak, and faint when assuming an upright position after sitting or lying down and should be taught to change positions slowly, avoid standing for long periods, do leg exercises to increase venous return, and lie or sit down when dizziness occurs. Direct-acting vasodilators often cause fluid retention; dry mouth may occur with diuretic use, and centrally acting alpha and beta blockers may cause bradycardia

Question 18

A 38-year-old man is treated for hypertension with triamterene and hydrochlorothiazide (Maxzide) and metoprolol
(Lopressor). Four months after his last clinic visit, his BP returns to pretreatment levels and he admits he has not
been taking his medication regularly. What is the nurse’s best response to this patient?
a. “Try always to take your medication when you carry out another daily routine so you do not forget to take it.”
b. “You probably would not need to take medications for hypertension if you would exercise more and stop
smoking.”
c. “The drugs you are taking cause sexual dysfunction in many patients. Are you experiencing any problems
in this area?
d. “You need to remember that hypertension can be only controlled with medication, not cured, and you must
always take your medication.”

Answer 18

c. “The drugs you are taking cause sexual dysfunction in many patients. Are you experiencing any problems
in this area?

Rational: Sexual dysfunction, which can occur with many of the antihypertensive drugs, including thiazide and potassium sparing diuretics and B-adrenergic blockers, can be a major reason that a male patient does not adhere to his treatment regimen. It is helpful for the nurse to raise the subject because sexual problems may be easier for the patient to discuss and handle once it has been explained that the drug may be the source of the problem

Question 19

A 78-year-old patient is admitted with a BP of 180/98 mm Hg. Which age-related physical changes may contribute
to this patient’s hypertension (select all that apply)?
a. Decreased renal function
b. Increased baroreceptor reflexes
c. Increased peripheral vascular resistance
d. Increased adrenergic receptor sensitivity
e. Increased collagen and stiffness of the myocardium
f. Loss of elasticity

Answer 19

a. Decreased renal function
c. Increased peripheral vascular resistance
e. Increased collagen and stiffness of the myocardium
f. Loss of elasticity

Rational: The age-related changes that contribute to HTN include decreased renal function, increased peripheral vascular resistance, increased collagen and stiffness of the myocardium, and decreased elasticity in large arteries from arteriosclerosis. The baroreceptor reflexes are blunted. The adrenergic receptor sensitivity and renin response are both decreased with aging

Question 20

What should the nurse emphasize when teaching a patient who is newly prescribed clonidine (Catapres)?

a. The drug should never be stopped abruptly
b. The drug should be taken early in the day to prevent nocturia
c. The first dose should be taken when the patient is in bed for the night
d. Because aspirin will decrease the drug’s effectiveness, Tylenol should be used instead

Answer 20

a. The drug should never be stopped abruptly

Rational: Centrally acting alpha adrenergic blockers may cause severe rebound HTN if the drugs are abruptly discontinued, and patients should be taught about this effect because many are not consistently compliant with drug therapy. Diuretics should be taken early in the day to prevent nocturia. The profound orthostatic hypotension that occurs with first dose peripheral acting alpha adrenergic blockers can be prevented by taking the initial dose at bedtime. Aspirin use may decrease the effectiveness of ACE inhibitors

Question 21

What is included in the correct technique for BP measurements?

a. Always take the BP in both arms
b. Position the patient supine for all readings
c. Place the cuff loosely around the upper arm
d. Take readings at least two times at least 1 minute apart

Answer 21

d. Take readings at least two times at least 1 minute apart

Rational: Correct technique in measuring BP includes taking and averaging two or more readings at least 1 minute apart. Initially BP measurements should be taken in both arms to detect any differences. If there is a difference, the arm with the higher reading should be used for all subsequent BP readings. The patient may be supine or sitting. The important points are that the arm being used is at the heart level and the cuff needs to fit snugly

Question 22

The unit is very busy and short staffed. What could the rN delegate to the unlicensed assistive personnel (UAP)?

a. Administer antihypertensive medications to stable patients
b. Obtain orthostatic BP readings for older patients
c. Check BP readings for the patient receiving IV sodium nitroprusside
d. Teach about home BP monitoring and use of automatic BP monitoring equipment

Answer 22

b. Obtain orthostatic BP readings for older patients

Rational: UAPs may check postural changes in BP as directed. The licensed practical nurse (LPN) may administer antihypertensive medications to stable patients. The RN must monitor the patient receiving IV sodium nitropursside, as he or she is in a hypertensive crisis. The RN must also do the teaching related to home BP monitoring

Question 23

Which manifestation is an indication that a patient is having a hypertensive emergency?

a. Symptoms of a stroke with an elevated BP
b. A systolic BP>180 mm Hg and a diastolic BP > 110 mm Hg
c. A sudden rise in BP accompanied by neurologic impairment
d. A severe elevation of BP that occurs over several days or weeks

Answer 23

c. A sudden rise in BP accompanied by neurologic impairment

Rational: Hypertensive emergency, a type of hypertensive crisis, is a situation in which a patient’s BP is severely elevated with evidence of acute target organ disease (e.g cerebrovascular, cardiovascular, renal, or retinal). The neurologic manifestations are often similar to the presentation of a stroke but do not show the focal or lateralizing symptoms of stroke. Hypertensive crisis are defined by the degree of organ damage and how rapidly the BP rises, not my specific BP measurements. A hypertensive urgency is a less severe crisis, in which a patients BP becomes severely elevated over hours or days but there is no evidence of target organ damage

Question 24

Which drugs are most commonly used to treat hypertensive crisis?

a. Labetalol and bumetanide (Bumex)
b. Esmolol (Brevibloc) and captopril (Captopril)
c. Enalaprilat (Vasotec) and minoxidil (Minoxidil)
d. Fenoldopam (Corlopam) and sodium nitroprusside (Nitropress)

Answer 24

d. Fenoldopam (Corlopam) and sodium nitroprusside (Nitropress)

Rational: Hypertensive crises are treated with IV administration of antihypertensive drugs, including the vasodilators sodium nitropurusside, fenoldopam, and nicardipine; adrenergic blockers such as labetalol, esmolol, and phentolamine; the ACE inhibitor enalaprilat; the calcium channel blocker clevidipine; nitroglycerin for myocardial ischemia; hydralazine with other medications; and oral captopril. Sodium nitroprusside is the most effective parenteral drug for hypertensive emergencies

Question 25

During treatment of a patient with a BP of 222/148 mm Hg and confusion, nausea, and vomiting, the nurse initially titrates the medications to achieve which goal?

a. Decrease the mean arterial pressure (MAP) to 129 mm Hg
b. Lower the BP to the patient’s normal within the second to third hour
c. Decrease the SBP to 160 mm Hg and the DBP to between 100 and 110 mm Hg as quickly as possible
d. Reduce the systolic BP (SBP) to 158 mm Hg and the diastolic BP (DBP) to 90 mm Hg within the first 2 hours

Answer 25

a. Decrease the mean arterial pressure (MAP) to 129 mm Hg

Rational: Initially the treatment goal in hypertensive emergencies is to reduce the mean arterial pressure (MAP) by no more than 20% to 25% in the first hour, with further gradual reduction over the next 24 hours. In this case the MAP is 222 + 2(148)/3=172, so decreasing it by 25% equals 129. Lowering the BP too far or too fast may cause a stroke, myocardial infarction (MI), or renal failure. Only when the patient has an aortic dissection, angina, or signs of an ischemic stroke does the SBP have to be lowered to 100 to 120 mm Hg or less as quickly as possible.

Question 26

What does the nursing responsibility in the management of the patient with hypertensive urgency often include?

a. Monitoring hourly urine output for drug effectiveness
b. Titrating IV drug dosages based on BP and HR measurements every 2-3 minutes
c. Providing continuous electrocardiographic (ECG) monitoring to detect side effects of the drugs
d. Instructing the patient to follow up with a health care provider within 24 hours after outpatient treatment

Answer 26

d. Instructing the patient to follow up with a health care provider within 24 hours after outpatient treatment

Rational: Hypertensive urgencies are often treated with oral drugs on an outpatient basis, but it is important for the patient to be seen by a health care provider within 24 hours to evaluate the effectiveness of the treatment. Hourly urine measurements, titration of IV drugs, and ECG monitoring are indicated for hypertensive emergencies