ch21.doc

[Osborn] chapter 21

Learning Outcomes [Number and Title] Learning Outcome 1 Compare and contrast the differences between the types of

hypertension: prehypertension, stage 1 hypertension, and stage 2 hypertension.

Learning Outcome 2 Describe the pathophysiology of hypertension.Learning Outcome 3 Discuss the risk factors associated with the development of

hypertension.Learning Outcome 4 Explain the therapeutic agents used to manage hypertension.Learning Outcome 5 Compare and contrast how social and cultural influences affect

the plan of care for the hypertensive patient.Learning Outcome 6 Develop a nursing plan of care with the hypertensive client.Learning Outcome 7 Discuss how multidisciplinary therapeutic interventions are

associated with patient outcome.

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.

1. A client’s visit to the health care clinic reveals a blood pressure of 130/82. The client’s blood pressure has been 138/88 at each of the last three clinic visits. The nurse recognizes that:

1. The client should be educated on lifestyle modifications now to diminish the client’s increased risk of developing stage 1 or stage 2 hypertension.

2. The client is at higher risk for developing stage 1 or stage 2 hypertension. The nurse will provide education on lifestyle modifications and anticipates the client will be started on medications at this visit.

3. The client is not at any higher risk for developing hypertension than anyone else and will therefore continue to be monitored periodically.

4. The client’s blood pressure meets the criteria for stage 1 hypertension. In addition to educating the client on lifestyle modifications, the nurse anticipates no need to start medication unless the blood pressure continues to climb.

Correct Answer: The client should be educated on lifestyle modifications now to diminish the client’s increased risk of developing stage 1 or stage 2 hypertension.

Rationale: This client’s blood pressure meets the criteria for prehypertension (systolic 120−139 or diastolic 80−89), according to the JNC 7 report, and has been elevated at multiple clinic visits. Prehypertension increases the client’s risk of developing stage 1 or stage 2 hypertension. At the prehypertensive stage, the primary goal is lifestyle modification and health education. Medications are not usually part of the therapeutic plan until stage 1 or stage 2 hypertension.

Cognitive Level: ApplyingNursing Process: PlanningClient Need: Health Promotion and MaintenanceLO: 1


2. A client’s visit to the health care clinic reveals a blood pressure of 142/90. The nurse’s next step would be to:

1. Check the client’s record for the past several blood pressure readings.2. Discuss the diagnosis of hypertension with the client.3. Notify the physician or primary health care provider immediately. 4. Identify medications the client has been taking.

Correct Answer: Check the client’s record for the past several blood pressure readings.

Rationale: This client’s blood pressure meets the criteria for stage 1 hypertension (systolic 140−159 or diastolic 80−99), according to the JNC 7 report. It is important for the nurse to first compare this blood pressure reading with previous blood pressure readings since the actual diagnosis of hypertension requires multiple readings that are high. Discussing the diagnosis of hypertension may be needed, but not until it is established that the client meets the criteria for stage 1 hypertension of multiple readings between systolic 140−159 or diastolic 80−99. The physician or primary health care provider does not need to be notified immediately, but will need to be ultimately involved in this client’s therapeutic plan. The nurse will identify the client’s medications, which may impact the blood pressure reading. However, this would follow establishing whether the high blood pressure reading is a pattern or a new event.

Cognitive Level: AnalyzingNursing Process: DiagnosisClient Need: Health Promotion and MaintenanceLO: 1


3. A client is asking about being diagnosed with stage 2 hypertension. The nurse identifies which of the following as a priority to teach the client?

1. The client will need to take the prescribed medication as directed.2. The client will need to exercise routinely or be faced with having to take

medication.3. The client can stop taking medication when the blood pressure returns to

normal limits.4. The client should limit activity to promote the blood pressure’s return to

normal.

Correct Answer: The client will need to take the prescribed medication as directed.

Rationale: The priority teaching includes ensuring the client understands that the medication must be taken as directed even when the client is feeling well. Stage 2 hypertensive clients will require not only exercise as part of the therapeutic plan, but also medication. Even though the client’s blood pressure will return to normal levels, the client should not stop taking the antihypertensive medications. The client requires exercise as part of the therapeutic plan, not limiting activity.

Cognitive Level: AnalyzingNursing Process: ImplementationClient Need: Health Promotion and MaintenanceLO: 1


4. The nurse recognizes that the client education has not been effective when the client states:

1. “Hypertension affects my blood vessels only if I have other underlying health problems.”

2. “Hypertension causes my blood vessels to become inflamed and decreases the blood supply to my organs if left untreated.”

3. “I am more prone to heart disease and eye problems if I discontinue my blood pressure medications.”

4. “Hypertension creates damage to my blood vessels even if I don’t have any symptoms.”

Correct Answer: “Hypertension affects my blood vessels only if I have other underlying health problems.”

Rationale: Essential and secondary hypertension can both have the same impact and effect on blood vessels. The effect of hypertension is not dependent upon the underlying cause. Hypertension does cause inflammation and decreased blood supply to organs if left untreated. Other health problems, such as heart disease and eye problems, can result from untreated hypertension. Symptoms from high blood pressure are not required to have underlying organ damage.

Cognitive Level: AnalyzingNursing Process: EvaluationClient Need: Health Promotion and MaintenanceLO: 2


5. A hospitalized client complains of fatigue, vision changes, and a significant headache. Which assessment finding would support a diagnosis of hypertension?

1. A retinal exam finding by the health care provider of microaneurysms and hard exudates

2. Blood pressure reading of 110/783. A one-time blood pressure reading of 140/994. Crackles bilaterally in all lung fields

Correct Answer: A retinal exam finding by the health care provider of microaneurysms and hard exudates Rationale: High blood pressure can be detected in the eye during a retinal exam by the presence of diffuse arteriole narrowing, microaneurysms, bleeding, cotton wool patches, and hard exudates. A blood pressure reading of 110/78 is within normal limits. A blood pressure reading of 140/99 is not significant with only one reading, but might be significant if repeated on more than one occasion. Crackles in all lung fields are not conclusive of hypertension without other assessment data.

Cognitive Level: Analyzing Nursing Process: PlanningClient Need: Physiological IntegrityLO: 2


6. The nurse is evaluating the effectiveness of a client’s antihypertensive medication, captopril (Capoten). The nurse knows this medication has less effectiveness on which of the following?

1. The 47-year-old African American client 2. The 23-year-old white male3. The 62-year-old white female4. The 78-year-old Asian male

Correct Answer: The 47-year-old African American client

Rationale: ACE inhibitors have less effectiveness on African American clients than other client types. African American clients also have a greater incidence of angioedema with ACE inhibitors than non-African Americans.

Cognitive Level: Analyzing Nursing Process: ImplementationClient Need: Physiological Integrity LO: 2


7. The nurse is screening clients for their risk potential of developing hypertension. The nurse knows that which of the following clients has the most risk factors for developing hypertension?

1. A 56-year-old African American male from Georgia with a BMI of 28, eats canned soups daily, episodic exercise

2. A 55-year-old African American female executive from Arkansas with a BMI of 24, most recent blood pressure readings were 118/78, exercises rarely

3. A 30-year-old Caucasian female from Maine with a BMI of 27, smokes two pack of cigarettes a day, exercises rarely

4. A 65-year-old Caucasian male from California with a BMI of 23, sleep apnea, exercises three times a week

Correct Answer: A 56-year-old African American male from Georgia with a BMI of 28, eats canned soups daily, episodic exercise

Rationale: It is important for nurses to identify clients who may have factors that put them at increased risk for hypertension based upon culture, environment, lifestyle, gender, genetics, and race. Each of the answer choices has some level of risk for developing hypertension. African Americans are almost twice as likely to develop hypertension as Caucasian Americans. Stress, obesity, cigarette smoking, alcohol consumption, diet, and comorbidities, as well as where an individual lives, can all increase the likelihood of hypertension.

Cognitive Level: AnalyzingNursing Process: AssessmentClient Need: Health Promotion and MaintenanceLO: 3


8. A client has been diagnosed with prehypertension. The nurse instructs the client in lifestyle changes before leaving the clinic. The client understands the instructions when which of the following statements is made?

1. “I cannot change my age or gender, but if I stop smoking and increase my exercise, I can reduce my chances of developing worse high blood pressure.”

2. “I can stop taking my diabetic medication to help reduce my chances of developing worse high blood pressure.”

3. “If I can stop smoking and increase my alcohol intake to help me relax more, I am less likely to develop worse high blood pressure.”

4. “To reduce my overall stress, I can eat more fast foods and prepared foods so that I have more time to exercise.”

Correct Answer: “I cannot change my age or gender, but if I stop smoking and increase my exercise, I can reduce my chances of developing worse high blood pressure.”

Rationale: Clients should be instructed in lifestyle choices to reduce their risk of hypertension. Age, race, genetics, and gender are nonmodifiable risk factors. Clients should understand ways they may modify and minimize other risk factors, such as smoking, weight, diet, excessive alcohol intake, stress, and management of comorbidities.

Cognitive Level: AnalyzingNursing Process: EvaluationClient Need: Health Promotion and MaintenanceLO: 3


9. An African American 45-year-old male has developed essential hypertension. The nurse knows which of the following is likely the biggest contributor to hypertension for this client?

1. This client is obese. 2. This client smoked for 6 months when he was 17 years old.3. This client has a family history of obesity.4. This client runs 4 miles per day.

Correct Answer: This client is obese.

Rationale: African American males have a higher incidence of hypertension than Caucasians. Obesity increases the risk for hypertension. Smoking for 6 months 28 years prior will not significantly impact this client’s risk for hypertension. A family history of obesity will be a risk factor, but not put the client at as high of risk as the client having obesity himself. Running 4 miles per day will decrease a client’s risk factor for hypertension.

Cognitive Level: AnalyzingNursing Process: PlanningClient Need: Physiological IntegrityLO: 3


10. A client has an order to take propranolol (Inderal) 80 mg twice daily. To maximize the client’s safety, it is imperative that the nurse teaches the client which of the following?

1. Do not abruptly stop the medication without consulting the physician.2. Stop the medication immediately if experiencing nausea or a cough, then

contact the health care provider.3. Contact the health care provider immediately if experiencing fatigue.4. If the client experiences headaches, the client should take an extra tablet.

Correct Answer: Do not abruptly stop the medication without consulting the health care provider.

Rationale: Propranolol (Inderal), a beta adrenergic blocking agent, may be administered for hypertension. The client needs to know that this medication should not be abruptly stopped. Abrupt withdrawal of the medication could cause life-threatening dysrhythmias. The client may experience fatigue. This is something the client should address with the health care provider upon the next visit unless the fatigue is debilitating. If the fatigue is overpowering, the client can contact the health care provider to discuss this. However, it is not cause for immediate contact. Taking extra medication is never advised unless the health care provider is consulted.

Cognitive Level: ApplyingNursing Process: ImplementationClient Need: Physiological Integrity LO: 4


11. A client has just been started on diltiazem hydrochloride (Cardizem SR) for high blood pressure. The nurse recognizes the client’s understanding when the client states:

1. “I need to use sunscreen every day.”2. “I will contact the health care provider immediately if I develop swelling of

the hands and feet.”3. “I can break this medication into smaller parts since it is too large to

swallow.”4. “I will take this medication only at bedtime because it makes me sleepy.”

Correct Answer: “I need to use sunscreen every day.”

Rationale: Diltiazem hydrochloride (Cardizem SR), a calcium channel blocker, works to decrease the blood pressure. This medication can cause photosensitivity and therefore sunscreen should be worn daily. Sustained-release (SR) types of medications should not be crushed or broken. Cardizem should be taken before meals and at bedtime. Swelling of the hands and feet may occur with angiotension-converting enzyme (ACE) inhibitors, not Cardizem.

Cognitive Level: AnalyzingNursing Process: EvaluationClient Need: Physiological IntegrityLO: 4


12. A hospitalized client is receiving hydralazine (Apresoline). The nurse is teaching the client about how to take the medication after discharge from the hospital. The nurse knows the teaching has been effective when the client states which of the following?

1. “I will take this medication every evening before bedtime.”2. “I can stop taking this medication after I am home for a few days.”3. “Any dizziness that might occur is the result of my kidneys not working right.”4. “I can expect a frequent headache.”

Correct Answer: “I will take this medication every evening before bedtime.”

Rationale: Hydralazine is a vasodilating medication given to reduce the blood pressure. The client has understood the instructions when the client verbalizes taking the medication at bedtime to reduce any side effects of hypotension. This medication should not be stopped without the advice of the physician. Dizziness and headaches are side effects of this medication and should be reported to the health care provider.

Cognitive Level: AnalysisNursing Process: ImplementationClient Need: Physiological IntegrityLO: 4


13. As the nurse is preparing a community education plan regarding high blood pressure, he knows that which of the following may impact the information that is shared?

1. When taking ACE inhibitors, African Americans have a higher incidence of significant side effects, such as angioedema.

2. Undergoing Westernization by American Indians helps them reduce their incidence of high blood pressure.

3. There is no difference in the incidence of hypertension across the United States.4. Caucasian Americans have a higher incidence of complications from high blood

pressure.

Correct Answer: When taking ACE inhibitors, African Americans have a higher incidence of significant side effects, such as angioedema.

Rationale: African Americans have up to four times the risk of Caucasians in experiencing angioedema and cough from ACE inhibitors. Westernization by American Indians increases—not lowers—their incidence of high blood pressure. There are regional differences for high blood pressure within the United States. African Americans are more likely to experience complications from high blood pressure.



14. A medical−surgical nurse is implementing a plan of care for a hypertensive client. Which of the following is the most important information to consider?

1. Whether the client utilizes any complementary and alternative therapies2. Whether the client has ever had symptoms from hypertension3. When the client last saw the physician4. The client’s family history

Correct Answer: Whether the client utilizes any complementary and alternative therapies

Rationale: While the client’s family history is important in determining the risk factors for hypertension, once the diagnosis has been made and a plan of care is being established, it is more important to note whether the client utilizes any complementary therapies since they will often conflict or enhance other therapies. Taking the complementary and alternative therapies into account will help to establish a plan of care that the client can manage. The plan of care is not dependent upon the client having ever had symptoms from the “silent killer” hypertension; however, the client needs to be aware of what symptoms are urgent or emergent, and these must be addressed with the health care provider once the client is discharged. When the client last saw the health care provider has no bearing on the plan of care.

Cognitive Level: ApplyingNursing Process: ImplementationClient Need: Physiological IntegrityLO: 5


15. A male client who has a career in the New York stock market has complained to the nurse how tired he has become. This client has a history of hypertension that is controlled with medication. The nurse has encouraged this client to begin to exercise. The primary purpose of this instruction is to:

1. Help the client decrease and manage stress.2. Assist the client to build new muscle.3. Decrease the client’s risk of tolerance to the medication.4. Improve the client’s mood.

Correct Answer: Help the client decrease and manage stress.

Rationale: The client has a stressful career that can eventually impact his health. The nurse advises the client to begin exercise primarily to assist with management of stress. It may assist with building new muscle, but that will not be beneficial for this client’s blood pressure, stress, or fatigue. Exercise will not decrease the risk of tolerance to medication; while it may improve the client’s mood, that is a peripheral benefit.

Cognitive Level: AnalysisNursing Process: ImplementationClient Need: Health Promotion and MaintenanceLO: 5


16. The medical−surgical nurse is providing the client and family with discharge instructions for the hypertensive client. The family is concerned about complications from hypertension. The nurse responds:

1. “There are potential complications, but the risks can be minimized if the hypertension is well controlled.”

2. “The complications are relatively minor.”3. “The physician will discuss the complications with you at a later date.”4. “The client could die if she doesn’t follow these instructions.”

Correct Answer: “There are potential complications, but the risks can be minimized if the hypertension is well controlled.” Rationale: The potential complications from hypertension can be minimized if hypertension is kept under control. Some of the potential complications can also be life threatening. The client should be aware of the seriousness of hypertension early in the treatment plan without unduly alarming the client. Cognitive Level: AnalyzingNursing Process: ImplementationClient Need: Physiological IntegrityLO: 6


17. After reviewing the hypertensive client’s chart and history, the nurse discovers the client has ongoing peripheral edema, as well as difficulty breathing and a cough following ambulation. The nurse chooses which of the following priority nursing diagnosis?

1. Impaired Tissue Perfusion 2. Imbalance Nutrition 3. Fatigue4. Risk of Noncompliance

Correct Answer: Impaired Tissue Perfusion

Rationale: The client with difficulty breathing and a cough following exercise, as well as ongoing peripheral edema, has impaired tissue perfusion related to resistance to blood flow. Imbalanced nutrition, fatigue, and risk of noncompliance may all be issues, but are not directly related to the presenting symptoms and would not carry as high of priority as impaired tissue perfusion.

Cognitive Level: AnalyzingNursing Process: PlanningClient Need: Physiological IntegrityLO: 6


18. A client who has been newly diagnosed with hypertension asks the nurse how long medication must be taken. The nurse knows the client requires more teaching when the client responds:

1. “I will stop the medication when I am feeling better.”2. “I will likely need to continue the medication for the rest of my life,”3. “I will take my medication as instructed.”4. “I may need to be on different types of medication.”

Correct Answer: “I will stop the medication when I am feeling better.”

Rationale: A client with hypertension will likely require medication for the rest of his or her life unless there are other lifestyle changes that impact the blood pressure or condition. The client should not stop the medication when feeling better. Taking the medication as instructed will ensure the greatest likelihood of a positive response to the medicine. The client may need to be on different medications all at once or have the medications changed throughout the course of a treatment regimen.

Cognitive Level: AnalysisNursing Process: ImplementationClient Need: Health Promotion and MaintenanceLO: 6


19. The nurse has performed a nutritional assessment and determined that several lifestyle modifications will need to be made. The nurse will want to include which other professional?

1. Dietician2. Physician3. Occupational therapist4. Clergy

Correct Answer: Dietician

Rationale: The dietician should be consulted for the hypertensive client who needs to make major dietary modifications since it is usually a significant lifestyle change. The health care provider will be collaboratively involved in the client’s care, but is not the nutritional expert. An occupational therapist is not needed at this time. The clergy may be appropriate at any time at the client’s request.



20. The client will be discharged on multiple antihypertensive medications. The nurse has reviewed the medications with the client. However, the client still has questions regarding the interactions and precautions for the medications. Whom should the nurse contact for the client prior to discharge?

1. Pharmacist 2. Physician3. Fitness leader 4. Dietician

Correct Answer: Pharmacist

Rationale: The pharmacist should be consulted for the hypertensive client who continues to have questions regarding medications; the pharmacist would be the most knowledgeable regarding the interactions and precautions. The health care provider will be collaboratively involved in the client’s care. The fitness leader and dietician will potentially play important roles in the management of this client’s illness, but would not be the experts for this client’s support regarding medications.

Cognitive Level: ApplyingNursing Process: ImplementationClient Need: Health Promotion and MaintenanceLO: 7


21. A client with recently diagnosed hypertension has been receiving guidance from many different multidisciplinary health care providers. The client asks the nurse why one person doesn’t just take care of her. The nurse responds:

1. “Clients have the best outcomes when there is a multidisciplinary approach to care.”

2. “Clients enjoy different providers; it keeps it interesting.”3. “Clients remember things when they hear it from different sources.”4. “Clients get a better-rounded education if it doesn’t come from the nurse.”

Correct Answer: “Clients have the best outcomes when there is a multidisciplinary approach to care.”

Rationale: Clients who receive multidisciplinary care receive instruction from the individuals who specialize in the corresponding topics. Therefore, they receive the best education from the individual experts in that area. A nurse’s role is to facilitate each of these encounters, and to provide supplemental information as needed. Although clients may enjoy different providers, that is not the reason for their involvement. Clients may recall information better when they hear it from different sources, and each specialty may also build upon another specialty. However, a client will receive the best information from the specialist in that topic area, not because it doesn’t come from the nurse.

Cognitive Level: ApplyingNursing Process: ImplementationClient Need: Health Promotion and MaintenanceLO: 7


ch21.doc

Documents

clients blood pressure

diagnosis of hypertension

prehypertensive stage

types of hypertension

development of hypertension

hypertensive client

title learning outcome

patient outcome