question

Pt BP 189/110, LDL 200mg/dl. Pt asks student nurse if he should be concerned about BP. How should student respond?

answer

Please sit quietly for a few minutes. I need to recheck BP

question

Pt-lost weight recently, stress, goes drinking, mother with DM, HTN, smokes and drinks 4-5 cups coffee/day

answer

Alcohol consumption-strongly associated with HTN

question

Student nurse rechecks: 180/106. According to assessment, what rec is most important for nurse to provide

answer

see HCP w/in next week for BP recheck

question

HCP states stage 2 primary HTN

answer

BP 184/98

question

Why do I have HTN?

answer

90-95% HTN no identifiable cause, even though there are several known contributing factors

question

Pt understand meds

answer

Take diuril early in day (diuretic) May experience impotence (S/E)

question

Health improvement-nothing left to enjoy-hat info is most important?

answer

Use of tobacco products is linked with increased risk for CV disease

question

Pt expresses interest in learning about reducing stress level. Saw tv about biofeedback and guided imagery, but can't imagine either of those techniques into his lifestyle. How should nurse respond?

answer

many methods to reduce stress, tell me about your workday

question

Nicotine gum to quit. What is most effective intervention to help Mark be successful this time?

answer

encourage mark to make quit plan

question

HTN damage to kidneys, heart, lungs, BV. Mark states his uncle/grandfather both died from aortic aneurysm. High BO cause this problem?

answer

advise him that his HCP may want to do further testing because of his family Hx

question

during initial visit, pt scheduled for ultrasound for aneurysm. nurse notes HCP asks mark to return for follow-up visit in 1month. Considering the overall plan of care, what is the primary reason for the nurse to encourage pt to keep his apt?

answer

Follow-up measurement of blood pressure (effectiveness of medications)

question

Teaching about aneurysm, what info should nurse include?

answer

maintain normal BP can effectively treat size of aneurysm-;5cm in size, Tx keep it under control and monitor every 6 mos

question

98.4 F, P 78, R 20, BP 148/90. What is most concern to nurse?

answer

Current 148/90-attaining and maintaining normal bp is essential

question

Nurse asks Mark if he is limiting salt intake. States wife fixes all the meals.Confirm she understands?

answer

"I am preparing a variety of fresh vegetables and avoiding processed foods"

question

Based on data, which nursing diagnosis should be included in plan of care?

answer

Ineffective health maintenance-reevalutated in order to become normotensive

question

HCP adds nefedipine (Procardia) to pt's other prescriptions. What instruction related to this med is essential for nurse to provide

answer

avoid grapefruit/grapefruit juice (decreases effectiveness of CCB)

question

What statement by Mark indicates to the nurse he understands plan of care?

answer

If BP is normal on next visit, will stay on meds for at least 1 year longer

question

Wife OD's on diazepam and alcohol. ER Mark is pale and complains onset of severe back pain--> triage nurse. What assessment data obtained during the triage assessment alerts the nurse that Mark needs immediate evaluation

answer

History of 3cm aortic aneurysm and sudden onset of backpain (could mean the aneurysm ruptured)

question

After exam, HCP writes several prescriptions. What prescription should nurse complete first?

answer

IV of 0.9% NS with large bore angiocath

question

When mark returns from radiology where the abdominal CT was performed, diagnosis of dissecting aortic aneurysm. Mark informed needs immediate surgery. Wife intubated and nonresponsive. Place nursing actions in numerical order from the first action through the last action.

answer

1. Notify Mark's children and family 2. Call report to the operating room staff 3. Get the surgical consent form signed 4. Consult a social worker

question

Which action can be safely delegated to the unlicensed assistive personnel (UAP)?

answer

Document list of Mark's personal belongings

question

After these tasks are completed, the nurse asks the UAP to obtain a second set of vital signs on Mark. What results indicates that this task was successfully delegated?

answer

UAP reports the current vital signs to the nurse

question

After first unit of packed RBC is available before Mark goes into OR, pt asks f he is going to die. He states he has never been around anyone who was dying and he is scared of what happens after death. What is the best response by the nurse?

answer

This is a frightening experience. Is there someone with whom you would like to talk about your fears?

question

Pt's kids arrive in ER and spend a few minutes with him before he goes to surgery. After a short period of time, the surgeon reports to the family that the aneurysm repair was unsuccessful and Mark died in surgery. One of pt's sons returns to the ER and starts yelling at the nurse. What is the nurse's best initial response?

answer

Acknowledge son's anger-understanding his anger is not directed personally at the nurse will help nurse in response in an effective, caring manner.

question

In addition to talking with pt's children and preparing his body for transport to the morgue, what action must the surgical nurse perform?

answer

Call the organ procurement agency for the region-Federal law nurse to notify the organ procurement agency for their region with all hospital deaths

question

Pt's wife has been taken to ICU. The next day, she becomes alert ; responsive. The kids tell ICU nurse that they do not want their mother of her husband's death. How should nurse respond?

answer

Talk further with the children and explore options with them-nurse needs to do a further assessment and allow the children to communicate their concerns

question

Kids are adamant that the nurse not tell their mother of father's death. Meanwhile wife continues to ask the nursing staff where her husband is. What resource is most valuable for nurse to use to resolve situation

answer

Hospital ethics committee- nurse needs to have others involved in this decision. Consulting the ethics committee is the appropriate channel to take to resolve this ethical dilemma

Care Case Study (1)- HTN

Unlock all answers in this set

Haven't found what you were looking for?

Search for samples, answers to your questions and flashcards