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?
“Please sit here quietly for a few minutes. I need recheck your blood pressure.
**Mr. Dunn’s blood pressure is high but may be temporarily elevated due to activity or stress. The blood pressure should be rechecked after the client rests for a few minutes.
What significant risk factor for hypertension does the student nurse identify for Mr. Dunn according to this health history?
Alcohol consumption
**Excessive alcohol intake is strongly associated with hypertension.
According to the assessment of this client, what recommendation is most important for the student nurse to provide Mr. Dunn?
See his healthcare provider within the next week for a BP recheck.
**Mr. Dunn’s blood pressure is significantly elevated. Since these BP readings were obtained on the same day, Mr. Dunn needs to see his healthcare provider soon for a second BP measurement so that a diagnosis can be determined and treatment initiated.
The student nurse continues to talk with Mr. Dunn about hypertension. Mr. Dunn states he feels great physically and doesn’t seen why he needs to see his healthcare provider. How should the student nurse respond?
“While often there are no symptoms, high blood pressure does cause damage to many organs.”
**Often clients with hypertension have no symptoms and organ damage may occur before the client becomes symptomatic.
A week later, Mr. Dunn has an appointment with his healthcare provider. After the exam, the healthcare providers explains to Mr. Dunn that he has stage 2, primary (essential) hypertension. What information obtained during the assessment supports this diagnosis?
Blood pressure of 184/98
**Stage 2 hypertension is described as a systolic blood pressure of greater than or equal to 1600 mm Hg or a diastolic blood pressure of greater than or equal to 100 mm Hg
The healthcare provider informs Mr. Dunn that he needs to be on a low-salt diet, stop smoking, limit his alcohol intake and decrease his stress level, and start taking chlorothiazide (Diuril) and atenolol (Tenormin). The nurse enters the room to give Mr. Dunn his prescriptions and spend some time teaching him about his care. Mr. Dunn asks the nurse to please call him Mark. In speaking with the nurse, Mark expresses concern that the healthcare provider did not prescribe any additional tests. “Shouldn’t the healthcare provider find out why I have hypertension?” How should the nurse respond to Mark’s question?
“90-95% of all cases of hypertension are without an identified cause, so unless there is some indicator in your health history the healthcare provider does not look for one.”
**Primary (essential) hypertension has no identifiable cause, even though there are several known contributing factors.
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Mark also asks the nurse about his medications, chlorothiazide (Diuril) and atenolol (Tenormin). The nurse reviews the medications, the side effects, and the importance of taking the medications on a daily basis. In evaluating Mark’s understanding, which statement(s) indicate that Mark understands the nurse’s instructions about his medications?
“I will need to take Diuril early in the day.
**Since Diuril is a diuretic, taking it later in the day may disrupt the client’s sleep.
“I may experience impotence with this drug regimen.”
**This is a common side effect of many antihypertensive medications, including atenolol (Tenormin), which is a beta blocker.
In discussing lifestyle modifications with Mark, what information is most important for the nurse to share with him?
Use of tobacco products is linked with increased risk for cardiovascular disease.
**Discontinuation of tobacco use decreases BP and has cardiovascular benefits within the first year of quitting.
Mr. Dunn expresses interest in learning more about how to reduce his stress level. He states that he has seen episodes on television about biofeedback and guided imagery, but he can’t imagine either of those techniques fitting into his life. How should the nurse respond?
Many methods can help reduce stress. Tell me about your work.
**With the response, the nurse helps Mark identify strategies that might fit into his lifestyle. The response empowers the client to be engaged in the process of determining which strategy will be most effective for him.
Mark admits that he has tried to quit smoking several times in his life by using nicotine gum. What is the most effective nursing intervention to help Mark be successful this time?
Encourage Mark to make a quit plan.
**A quit plan, which includes the quit data, notifying friends and relatives of the plan to quit, anticipating withdrawal symptoms, and throwing away all tobacco products on the quit date is an excellent method to quit smoking. Using more than one method helps to ensure success. Mark’s use of the nicotine gum along with a quit plan may increase the potential for success.
Mark expresses concern about the problems that can arise if he doesn’t get his blood pressure under control. The nurse explains that hypertension can damage the kidneys, heart, lungs, and blood vessels. Mark states that he had an uncle and grandfather who both died from an aortic aneurysm. He asks the nurse if high blood pressure causes this problem. How should the nurse respond to Mark’s concern?
Advise him that, due to his family history, his healthcare provider may want to do further testing.
**Studies have shown a strong genetic predisposition in the development of abdominal aortic aneurysms. This response provides immediate feedback that addresses the client’s concern.
During the initial office visit, Mark is also scheduled for an abdominal ultrasound to determine the presence of an aneurysm. The nurse notes that the healthcare provider has asked Mark to return for a follow-up visit in 1 month. Considering the overall plan of care, what is the primary reason for the nurse to encourage Mark to keep his next appointment?
Follow-up measurement of his blood pressure.
**Mark has just been started on antihypertensive medications. The effectiveness of this treatment needs to be assessed. Many people who are on antihypertensive medications are still hypertensive. Follow-up evaluation is essential.
Mark returns to the office in 1 month with his wife. The ultrasound exam showed the presence of a 3 cm Fusiform aneurysm on the abdominal aorta. In teaching Mark about the aneurysm, what information should the nurse include?
Maintaining a normal blood pressure can effectively treat this size of an aneurysm.
**For aneurysms smaller than 5 cm in size, the treatment of choice is to keep the client’s blood pressure under control and to monitor the size of the aneurysm every 6 months.
Mark’s vital signs are T 98.4 F, P 78, R 20, and BP 148/90. Mark states he has been feeling fine except that he seem to be more tired than he usually is and has had some trouble sleeping. When asked, Mark replied that he has cut down to only 1 pack of cigarettes a week and he has signed up to take a class on reducing stress next month. Which assessment finding is of most concern to the nurse?
Current blood pressure reading of 148/90
**Mark’s BP is still hypertensive. With the presence of an abdominal aortic aneurysm (AAA), attaining and maintaining a normal BP is essential.
The nurse asks Mark if he is limiting his salt intake. He states that his wife fixes all the meals. Which statement by his wife shows she understands a 2-gm sodium diet?
“I am preparing a variety of fresh vegetables and avoiding processed foods.”
**Processed foods are a major source of sodium. Replacing processed foods with fresh is a key to maintaining a low-sodium diet.
Based on the data the nurse has obtained, which nursing diagnosis should be included in the plan of care?
Ineffective health maintenance
**Mark remains hypertensive. His treatment regimen needs to be re-evaluated in order for Mark to become normotensive.
The healthcare provider adds nifedipine (Procardia) to Mark’s other prescriptions. What instruction related to this medication is essential for the nurse to provide Mark?
Avoid eating fresh grapefruit or grapefruit juice.
**Grapefruit decreases the effectiveness of nifedipine (Procardia), a calcium channel blocker.
What statement by Mark indicates to the nurse that he understands his current plan of care?
If my blood pressure is in the normal range on my next visit, I will probably continue on these medications for at least one year.
**Step-down therapy is not started until after 1 year of good blood pressure control.
Six months later, Mark’s wife takes an overdose of diazepam and alcohol. She is brought to the ED by the EMS. Mark arrives a little while later from work. He is obviously upset and very angry. As Mark is giving information to the registration clerk, he becomes pale and complains of the sudden onset of severe back pain. Mark is taken to the triage nurse. What assessment data obtained during the triage assessment alerts the nurse that Mark needs immediate medical evaluation?
History of 3 cm aortic aneurysm and sudden onset of back pain.
**The sudden onset of back pain in the client with a history of an aneurysm is a sign that the aneurysm may be dissecting or may have ruptured.
After examining Mark, the healthcare provider writes several prescriptions. Which prescription should the nurse complete first?
IV of 0.9% NS with large bore angiocath.
**When dissecting or ruptured aneurysm occurs, the client requires large amounts of fluid replacement to maintain the blood pressure. It is essential that an IV be started before Mark’s blood pressure starts to fall.
When Mark returns from radiology where the abdominal CT was performed, the diagnosis of dissecting aortic aneurysm is made. Mark is informed that he needs immediate surgery. Unfortunately, his wife is intubated and non responsive. Place the nursing actions in numerical order from the first action through the last action.
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.
Several things need to be done before Mark goes to surgery. Which action can be safely delegated to the unlicensed assistive personnel (UAP)?
Document a list of Mark’s personal belongings.
**This is the only action listed that does not require the expertise of the nurse.
After these tasks are completed, the nurse asks the UAP to obtain a second set of vital signs on Mark. What result indicates that this task was successfully delegated?
The UAP reports the current vital signs to the nurse.
**For delegation to be complete, not only must the right task be assigned to the right person and completed, but the results must be reviewed by the nurse.
The first unit of PRBC’s is available before Mark goes to the operating room. While the nurse is hanging the unit of blood, Mark asks if he is going to die. Mark states that he has never been around anyone who was dying and he is scared of what happens after death.
“This is a frightening experience. Is there someone with whom you would like to talk about your fears?”
**The nurse acknowledges Mark’s feelings and addresses the issue.
Mark’s children arrive in the ED 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 Mark’s sons returns to the ED and starts yelling at the nurse. What is the nurse’s best initial response?
Acknowledge the son’s anger.
**Understanding that the son’s anger is not directed personally at the nurse will help the nurse respond to the son in an effective, caring manner.
In addition to talking with Mark’s children and preparing his body for transport to the morgue, what action must the surgical nurse perform?
Call the organ procurement agency for the region.
**Federal law requires the nurse to notify the organ procurement agency for their region with all hospital deaths.
Mark’s wife has been taken to the ICU. The next day, she becomes alert and responsive. The children tell the ICU nurse that they do not want their mother told of her husband’s death. How should the nurse respond?
Talk further with the children and explore options with them.
**The nurse needs to do a further assessment and allow the children to communicate their concerns.
The children are adamant that the nurse not tell their mother of their father’s death. Meanwhile, Mark’s wife continues to ask the nursing staff where her husband is. What resource is most valuable for the nurse to use to resolve this situation?
The hospital ethics committee.
**The nurse needs to have others involved in this decision. Consulting the ethics committee is the appropriate channel to take to resolve this ethical dilemma.