question

1. Mr. Dunn's blood pressure reading is 189/110. His LDL cholesterol reading is 200 mg/dl. He asks the student nurse if he should be concerned about his blood pressure. How should the student respond?

answer

Please sit here quietly for a few minutes. I need to recheck your blood pressure.

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2. What significant risk factor for hypertension does the student nurse identify for Mr. Dunn according to this health history?

answer

Alcohol consumption

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3. According to the assessment of this client, what recommendation is most important for the student nurse to provide Mr. Dunn?

answer

See his healthcare provider within the next week for a BP recheck

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4. The student nurse continues to talk with Mr. Dunn about hypertension. Mr. Dunn states he feels physically and does not see why he needs to see his healthcare provider. How should the student nurse respond?

answer

While often there are no symptoms, high blood pressure does cause damage to many organs

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5. What information obtained during the assessment supports this diagnosis (stage 2, primary [essential] hypertension)?

answer

Blood pressure of 184/98

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6. He asks, "shouldn't the healthcare provider find out why I have hypertension?" How should the nurse respond to Mark's question?

answer

90-95% of all cases of hypertension are without an identified cause, so unless there is some indicator in you health history, the healthcare provider does not look for one

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7. In evaluating Mark's understanding, which statement(s) indicate that Mark understands the nurse's instructions about his medications?

answer

-I will need to take Diuril early in the day -I may experience impotence with this drug regimen

question

8. In discussing these lifestyle modifications with Mark, what information is most important for the nurse to share with him?

answer

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

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9. Mr. Dunn expresses interest in learning more about how to reduce his stress level. How should the nurse respond?

answer

Many methods can reduce stress. Tell me about your work day

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10. What is the most effective nursing intervention to help Mark be successful this time?

answer

Encourage Mark to make a quit plan

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11. He asks the nurse if high blood pressure causes this problem. How should the nurse respond to Mark's concern?

answer

Advise him that his healthcare provider may want to do further testing because of his family history

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12. Considering the overall plan of care, what is the primary reason for the nurse to encourage Mark to keep his next appointment?

answer

Follow-up measurement of his blood pressure

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13. In teaching Mark about the aneurysm, what information should the nurse include?

answer

Maintaining a normal blood pressure can effectively treat this size of aneurysm

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14. Which assessment finding is of most concern to the nurse?

answer

Current blood pressure reading of 148/90

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15. Which statement by his wife shows she understands a 2-gm sodium diet?

answer

"I'm preparing a variety of fresh vegetables and avoiding processed foods."

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16. Based on the data the nurse has obtained, which nursing diagnosis should be included in the plan of care?

answer

Ineffective health maintenance

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17. What instruction related to this medication is essential for the nurse to provide Mark?

answer

Avoid eating fresh grapefruit or grapefruit juice

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18. What statement by Mark indicates to the nurse that he understands his current plan of care?

answer

"If my blood pressure is in the normal range on my next visit, I will probably continue on these medications for at least a year."

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19. What assessment data obtained during the triage assessment alerts the nurse that Mark needs immediate medical evaluation?

answer

History of 3 cm aortic aneurysm and sudden onset of back pain

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20. Which prescription should the nurse complete first?

answer

IV of 0.9% Normal Saline with large bore angiocath

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21. Place the 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

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

answer

Document a list of Mark's personal belongings

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23. What result indicates that this task was successfully delegated?

answer

The UAP reports the current vital signs to the nurse

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24. Mark asks if he's going to die. 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?"

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25. One of Mark's sons returns to the ED and starts yelling at the nurse. What is the nurse's best initial response?

answer

Acknowledge the son's anger

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26. In addition to talking with Mark'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

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27. The children tell the ICU nurse that they do not want their mother told of her husband's death. How should the nurse respond?

answer

Talk further with the children and explore options with them

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28. What resource is most valuable for the nurse to use to resolve this situation?

answer

The hospital ethics committee

HESI Case Studies-Hypertension (Mark Dunn) – Flashcards

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