what goes up must come down: hypertension and the jnc-8 ......hypertension and the jnc-8 guidelines...

www.AmericanNurseToday.com June 2015 American Nurse Today 1

ESSENTIAL (primary) hypertensionis one of the most important pre-ventable contributors to illness anddeath in the United States. Fre-quently termed the silent killer, hy-pertension progresses with fewsymptoms until blood pressure(BP) rises to dangerous levels. Anestimated 78 million nonpregnantAmericans ages 20 and older havehypertension, making this diseasethe most common reason for pri-mary care physician visits—andmaking antihypertensive drugs themost frequently prescribed medica-tions. (See Hypertension by thenumbers.)

We still have a long way to goto control this disease. In 2014, theEighth Joint National Committee onthe Prevention, Detection, Evalua-tion, and Treatment of High BloodPressure (known as JNC-8) devel-oped evidence-based guidelines formanaging hypertension in adults.These guidelines focus on pharma-cologic management and treatmentcriteria, but retain the definitions ofhypertension and prehypertension,as well as lifestyle modifications, ofthe previous report (JNC-7).

Normal BP is defined as systolicBP below 120 mm Hg and a dias-tolic BP below 80 mm Hg. Highervalues indicate prehypertensionand varying stages of hypertension,depending on the specific BP read-ing. (See Hypertension stages.)

Risk factors Hypertension results from severalgenetic and lifestyle factors. Genet-ic factors, such as one or both par-

ents with hypertension, double therisk. Even though systolic BP natu-rally increases with age, obesitycontributes to an earlier rise. Ahigh-sodium diet, excessive alcoholconsumption, and lack of physicalactivity are modifiable risk factors.

Complications Hypertension is a major risk factorfor diseases of the heart, brain, kid-neys, and eyes. It’s also the mostcommon comorbidity, especially inpatients with cardiovascular disor-ders. For example, 51% of patients

with cardiovascular disease have ahistory of hypertension.

Cardiovascular complicationsLeft ventricular hypertrophy (LVH)is a common manifestation ofchronic hypertension. The left ven-tricle encounters greater resistancethan the right, so the muscle be-comes larger and thicker, muchlike a weightlifter’s muscles getbigger with training. LVH increasesthe likelihood of myocardial is-chemia because the increased mus-cle mass demands a greater bloodsupply; also, when overall demandincreases, ability of the coronaryarteries to dilate diminishes.

Increased left ventricular mass also strains the cardiac conductionsystem, prolonging the depolariza-tion/repolarization sequence in theventricles. Called prolonged QT in-terval, this effect increases the ven-tricle’s relative refractory period,making the myocardium vulnerableto potentially fatal ventricular ar-rhythmias, such as ventricular tachy -cardia, torsades de pointes, andventricular fibrillation.

Because hypertrophied ventriclesdon’t pump blood efficiently, therisk of heart failure (HF) associatedwith impaired systolic and diastolicfunction increases. Among patientswith HF, 74% have a history of hy-pertension. The higher average BPa person experiences over time,the greater the HF risk. In addition,69% of patients who experienceacute myocardial infarction (AMI)are hypertensive. AMI patients withhypertension are at significantly

What goes up must come down:Hypertension and the JNC-8

guidelines What you need to know about the new treatment guidelines

By Terri Townsend, MA, RN, CCRN-CMC, CVRN-BC, and Pamela Anderson, MS, RN, ANP-BC, CCRN

LEARNING OBJECTIVES

1. Identify the stages of hyperten-sion.

2. Describe complications associatedwith hypertension.

3. Discuss management of hyperten-sion based on the JNC-8 guide-lines.

The author and planners of this CNE activity havedisclosed no relevant financial relationships withany commercial companies pertaining to thisactivity.

Expiration: 6/1/18

CNE1.22 contact

hours

2 American Nurse Today Volume 10, Number 6 www.AmericanNurseToday.com

higher risk for HF than normoten-sive AMI patients.

Neurovascular complicationsHypertension is the most commoncause of nontraumatic intracerebralhemorrhage in adults. The primaryvessels involved are the penetratorarteries branching at 90-degree an-gles to the parent vessel (common-ly the middle cerebral artery). Theincreased force of blood flowcaused by hypertension weakensthe arterial wall, eventually causingsmall breaks in the wall itself. Mi-crohemorrhages occur, leading toclot formation. Significant symp-toms rarely arise. If the hemorrhagebecomes too large to be containedby the normal thrombus formation,a hemorrhagic stroke ensues. Neu-ronal ischemia stems both fromedema at the site and thehematoma itself.

Hypertension also is a major

preventable cause of ischemicstroke in adults. Of patients pre-senting with their first stroke, 77%are hypertensive. Hypertension ag-gravates atherosclerosis of thecarotid arteries and aortic arch andcauses atherosclerosis in the brain’ssmall blood vessels. In this case,abrupt BP changes lead to a dra-matic decrease in cerebral bloodflow from arterial stiffness and sub-sequent lack of compliance. Withstroke ranking as one of the topcauses of death in the UnitedStates, we need to eliminate thispreventable risk factor.

Renal complicationsHypertension increases the risk forrenal disease and hastens its pro-gression; it also raises the risk ofcomplications from renal disease.Decreased renal function caused byhypertension starts without symp-toms. When symptoms arise, noc-

turia presents early due to the kid-ney’s diminished ability to concen-trate urine. In individuals with bothhypertension and diabetes, microal-buminuria arises as a warning signof underlying renal damage thatmay result in chronic and ultimate-ly end-stage renal disease (ESRD).

Even individuals with prehyper-tension have an increased risk ofchronic kidney disease. Among thevarious cultural groups, AfricanAmericans have the highest preva-lence of hypertension in the world.In African American adults, hyper-tension occurs at a younger ageand average BP is higher than inother racial and cultural groups.Hypertensive African Americanhave a 4.2 greater risk of ESRD anda twofold risk of fatal stroke.

Eye complicationsHypertension causes retinal dam-age, including arterial narrowing,retinal ischemia, optic disc edema,arteriosclerosis, star-shaped exu-dates, and vascular wall thickening.Individuals typically experiencefew or no symptoms until damageis advanced. When symptoms oc-cur, they include blurred vision,headache, or both. Otherwiseasymptomatic hypertension may beidentified when an optometristrefers a patient with visual changesto a primary care provider. Withouttreatment to control BP, permanentretinal damage occurs.

Treatment goalsJNC-8 guidelines for hypertensiontreatment stress the importance ofsystolic and diastolic BP control,using age and comorbidities fortreatment recommendations. (SeeRecommended blood pressuregoals.) Lifestyle modifications arerecommended for all patients withhypertension, but diet and exercisealone aren’t always enough to re-duce BP to optimal levels.

Lifestyle changesEvidence-based lifestyle changes

Hypertension by the numbers For more than 40 years, campaigns to increase Americans’ awareness of their bloodpressure (BP) and how hypertension contributes to illness and death have beenfairly successful. More American adults are now aware of their BP values. Of Ameri-cans diagnosed with hypertension, 82% are aware of their condition, 75% are pre-scribed antihypertensive medications, and 53% maintain their target BP.

Hypertension accounts for roughly $46 billion in direct and indirect medicalcosts in the United States.

The chart below shows systolic and diastolic blood pressure ranges for the fourstages of hypertension.

Systolic Diastolic Stage blood pressure blood pressure

Prehypertension (untreated or 120 to 139 mm Hg 80 to 89 mm Hgundiagnosed hypertension)

Stage 1 hypertension 140 to 159 mm Hg 90 to 99 mm Hg

Stage 2 hypertension Equal to or above 100 mm Hg or higher 160 mm Hg

Hypertensive crisis Above 120 mm Hg with acute end-organ damage

Blood pressure criteria are based on The Seventh Report of the Joint National Committee on Prevention, De-tection, Evaluation, and Treatment of High Blood Pressure (JNC-7).

Hypertension stages


can be highly effective in loweringBP and are first-line recommenda-tions for all patients with hyperten-sion. Such changes include homeBP monitoring, diet, exercise, andweight reduction when indicated.Smoking cessation is highly recom-mended to reduce all cardiovascu-lar disease risk.

Home BP monitoring gives pa-tients the opportunity to take own-ership and become a partner inmanaging hypertension. Seeing evi-dence of reduced BP firsthand canencourage patients to continue tomake healthy lifestyle changes andadhere to the prescribed medica-tion regimen. Conversely, whenhome monitoring indicates an in-crease in BP, the patient is morelikely to make further changes orseek medical attention in a timelymanner.

Weight loss and sodium restric-tion through dietary changes areevidence-based methods of de-creasing BP. Approximately 25% ofAmericans with hypertension areoverweight or obese. Even modestweight loss can lower blood pres-sure. Systolic BP decreases approx-imately 1 mm Hg for every poundof weight lost.

The DASH diet (Dietary Ap-proaches to Stop Hypertension) isrich in fruits, vegetables, low-fatdairy products, whole grains, poul-try, fish, and nuts and low insweets, red meat, and saturatedfats. According to the AmericanHeart Association, eating the DASHdiet can lower systolic BP an aver-age of 5 mm Hg. Current recom-mendations for sodium intakerange from 1,500 to 2,300 mg/day.However, most Americans consumeat least 50% more than the recom-mended amount. Foods highest insodium include processed meats,baked goods, processed cheese,frozen dinners, and salad dressings.Reducing sodium intake to the rec-ommended daily amount can de-crease BP as much as 8 mm Hg.

Other lifestyle modifications in-

clude limiting alcohol consumptionto one or two drinks per day andincreasing physical activity. Engag-ing in such activities as brisk walk-ing at least 30 minutes daily 5 daysa week can reduce systolic BP asmuch as 9 mm Hg. What’s more,physical activity improves generalcardiovascular health.

Pharmacologic treatment JNC-8 recommendations focus onthe main purpose of hypertensiontreatment—achieving and maintain-ing BP in the goal range. If lifestylechanges alone aren’t sufficient tomeet BP goals, pharmacologictreatment is recommended, withfollow-up within 1 month. Failureto meet goal BP values warrants anincreased dosage, additional med-ications, or both. (See Antihyper-tensive classes.)

First-line antihypertensivesJNC-8 limits first-line antihyperten-sives to calcium channel blockers(CCBs), thiazide-type diuretics, an-giotensin-converting enzyme in-hibitors (ACEIs), and angiotensin IIreceptor blockers (ARBs).

CCBs. These drugs bind to L-typecalcium channels in vascular smoothmuscle, cardiac nodal cells, and car-diac myocytes. They relax vascular

smooth muscle, which decreasessystemic vascular resistance and ulti-mately reduces BP. The two majortypes of CCBs are the dihydropy-ridines and non-dihydropyridines. • Dihydropyridines are potent va-

sodilators with minimal effect onconduction and cardiac contrac-tility.

• Non-dihydropyridines primarilyaffect cardiac conduction andcontractility, with a minimal va-sodilator effect. Adverse effects of CCBs include

dizziness, headache, peripheraledema, flushing, and light-headed-ness. Constipation, a major adverseeffect of verapamil, affects 25% ofpatients. Peripheral edema associat-ed with CCBs stems from fluid re-distribution from the vascular spaceto the interstitial space, allowingtransmission of more systemic pres-sure to the capillary system. Edemafrom CCBs remains resistant to di-uretic therapy. Concurrent use ofCCBs with angiotensin-convertingenzyme inhibitors (ACEIs) reducesfrequency of peripheral edema. Ve-nous dilation from ACEIs allows re-moval of sequestered fluid in theinterstitial space by arterial dilationcaused by CCBs.

Nursing actions for patients re-ceiving CCBs include the following:

The chart below shows blood pressure (BP) goals according to population, as recom-mended by the Eight Joint National Committee on the Prevention, Detection, Evalu-ation, and Treatment of High Blood Pressure.

Population Systolic BP goal Diastolic BP goal

General population ages Below 150 mm Hg Below 90 mm Hg60 and older

General population younger Below 140 mm Hg Below 90 mm Hgthan age 60

Adults ages 18 and older with Below 140 mm Hg Below 90 mm Hgchronic kidney disease

Adults ages 18 and older with Below 140 mm Hg Below 90 mm Hgdiabetes

Source: James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of highblood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee(JNC-8). JAMA. 2014;311:507-20.

Recommended blood pressure goals


• Monitor for bradycardia, becausethese drugs are contraindicatedin third-degree heart block.

• Teach the patient the importanceof taking daily weights.

• Advise patients that verapamilcommonly causes constipation.

• Caution patients not to drinkgrapefruit juice during CCB ther-apy because this can increasemedication levels in the blood,causing a more pronounced an-tihypertensive effect. Thiazide-type diuretics. These

drugs reduce BP by blocking thesodium-chloride transport mecha-nism in the distal convolutedtubule, which causes fluid loss andreduces blood volume and cardiacoutput. In patients with both hy-pertension and HF, these medica-tions improve HF outcomes. Anti-hypertensive regimens in patientsolder than age 75 with impaired re-nal function should include thi-azide-type diuretics and CCBs in-stead of ACE inhibitors and ARBs,because the latter increase the risk

of hyperkalemia and further renalimpairment.

Side effects of thiazide-type di-uretics may include hypokalemia,hyponatremia, hypomagnesemia,hyperuricemia, and increased glu-cose and cholesterol levels. How-ever, low-dose therapy can mitigatethese effects.

Nursing actions for patients re-ceiving thiazide-type diuretics in-clude the following:• Instruct patients to weigh them-

selves daily.• Assess fluid volume and elec-

trolyte balance.• In males, watch for adverse ef-

fects on sexuality, including de-creased libido and impotence.

• Be aware that chlorthalidone is athiazide-type diuretic and has amore pronounced antihyperten-sive effect than hydrochloroth-iazide. ACEIs. These drugs lower BP

primarily by reducing angiotensinII. They also decrease breakdownof kinins, which may affect BP

from direct dilation and increasedproduction of vasodilator prosta -glandins. Captopril reduces BP byinhibiting the enzyme that convertsangiotensin I to angiotensin II andstimulating the kallikrein-kinin sys-tem. This results in decreased pe-ripheral vascular resistance.

In addition, ACEIs also are pre-scribed to treat HF and chronickidney disease (CKD). In CKD,these drugs reduce urinary proteinexcretion. (High urinary proteinlevels are linked to decreasedglomerular filtration rates.) Becauseof the association between hyper-tension and albuminuria, ACEIsmay be given to patients with dia-betes; albuminuria increases asCKD progresses.

In addition, ACEIs promote re-gression of left ventricular hyper-trophy to a greater extent than betablockers. Unlike beta blockers anddiuretics, they don’t adversely af-fect cholesterol and glucose levels.However, they frequently causecreatinine elevations, resulting in

This chart lists antihypertensive medication classes recommended by the Eight Joint National Committee on the Prevention, De-tection, Evaluation, and Treatment of High Blood Pressure (JNC-8). These drugs should be prescribed according to JNC-8 recom-mendations—not the order in which they appear below.

First-line drug therapy Second- or third-line drug therapy Later-line drug therapy

• Calcium channel blockers (CCBs) • Increased doses of first-line drugs • Alpha-1 blockers, beta blockersExamples: amlodipine, diltiazem ER, • Combination of thiazide-type diuretics Examples: doxazosin mesylate, nicardipine and CCBs, ACEIs, or ARBs metoprolol, terazosin given

• Angiotensin-converting enzyme concurrently with atenololinhibitors (ACEIs) • Vasodilating beta blockersExamples: captopril, enalapril, lisinopril Example: nebivolol

• Thiazide-type diuretics • Central alpha-2 adrenergic Examples: chlorthalidone, agonistshydrochlorothiazide, indapamide Example:methyldopa

• Angiotensin receptor blockers (ARBs) • Direct vasodilatorsExamples: irbesartan, valsartan Example: hydralazine • Loop diuretics Example: furosemide • Aldosterone antagonists Example: spironolactone • Peripherally acting adrenergic antagonists Example: reserpine

Source: James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members ap-pointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311:507-20.

Antihypertensive medication classes


hyperkalemia. Hyperkalemia alsocan occur when ACEIs are givenwith potassium-sparing diuretics. Ifthe patient’s creatinine and potassi-um levels rise, the dosage must beadjusted or the drug may need tobe discontinued.

Side effects of ACEIs include hy-potension, hyperkalemia, and acuterenal failure. Cough, angioedema,and anaphylactic reactions stemfrom increased kinins.

Nursing actions for patients re-ceiving ACEIs include the following:• Monitor for creatinine elevations

and hyperkalemia.• Advise patients to change posi-

tion slowly to avoid orthostatichypotension.

• Monitor blood pressure after theinitial dose to evaluate the pa-tient’s response. Hypotension orsyncope may occur when thera-py is initiated, usually with thefirst several doses.

• Be aware that captopril maycause neutropenia, agranulocyto-sis, anemia, and thrombocytope-nia. Bone marrow depression ismore common in patients withpreexisting renal disease or col-lagen vascular disorders.

• Know that these drugs are con-traindicated in pregnant patientsbecause they may cause fetalbirth defects and fetal death.ARBs. Like ACEIs, ARBs target

the renin-angiotensin system. How-ever, they are more selective, withno effect on bradykinin. JNC-8guidelines recommend that clini-cians prescribe either an ACEI oran ARB for all patients older thanage 18 with a history of CKD, re-gardless of ethnicity. This recom-mendation is based on evidence ofimproved renal outcomes withthese medications. (Evidence sup-porting the use of an ACEI or ARBin patients with cardiovascular dis-ease and CKD is lacking.)

Side effects of ARBs may includehypotension (more common withARBs than ACEIs), hyperkalemia,syncope, anaphylactic reactions,

angioedema, and increased serumcreatinine levels. Cough, whenpresent, may be less pronouncedwith ARBs than ACEIs. Anaphylac-tic reactions are more likely in he-modialysis patients who are dia-lyzed with a synthetic noncellulosemembrane, which is highly perme-able and causes increased kininproduction.

Like ACEIs, ARBs can causeacute renal failure. With ACEIs, thisis more likely to occur in patientswith bilateral renal artery stenosis.In patients receiving ARBs, acuterenal failure may result from ex-treme volume depletion. Olmesar-tan may cause a sprue-like en-teropathy that develops months oryears after drug initiation. Hall-marks of this condition includemarked diarrhea with weight lossand intestinal biopsy that revealsvillous atrophy. Signs and symp-toms resolve with drug discontinu-ation but recur if the drug is re -introduced.

Nursing actions for patients re-ceiving ARBs include the following:• Monitor for bone marrow sup-

pression.• Assess for orthostatic hypoten-

sion.• Evaluate fluid and electrolyte

status.• Check for signs and symptoms

of angioedema. • Know that ARBs are contraindi-

cated in pregnant patients be-cause they can cause fetal birthdefects and fetal death.

Later-line antihypertensivesAccording to JNC-8 guidelines, sec-ond-and third-line antihypertensivetherapy includes higher doses orcombinations of thiazide-type di-uretics, CCBs, ACEIs, and ARBs.

JNC-8 classifies beta blockers asa later-line alternative, due to anincreased rate of cardiovasculardeath, stroke, and myocardial in-farction. Other later-line drugs in-clude alpha blockers (which maylead to worse cerebrovascular and

cardiovascular outcomes), directvasodilators, aldosterone antago-nists, and peripherally actingadrenergic antagonists.

Going where the evidence leads usHypertension is a preventable con-tributor to cardiovascular disease,renal disease, and neurovasculardisease—often with devastating re-sults. Patient awareness of BP read-ings and their meaning can go along way toward making patientsactive participants in their healthcare. Evidence-based lifestyle modi-fications, including diet, physicalactivity, sodium reduction, andmoderation of alcohol use, signifi-cantly decrease BP and help pre-vent complications. Nurses canplay an important role in educatingand encouraging patients to makenecessary lifestyle changes.

JNC-8 recommendations for phar-macologic treatment of hypertensionare evidence-based guidelines. Rec-ommended antihypertensives havedemonstrated effectiveness andsafety in lowering BP and reducingcomplications of hypertension.Through a combination of lifestylemodifications and pharmacologictreatment, patients can work togeth-er with healthcare providers to re-duce BP to normal levels and opti-mize their well-being for manyyears. �

Selected referencesAmerican Heart Association. Managing bloodpressure with a heart-healthy diet. UpdatedAugust 14, 2014. www.heart.org/HEARTORG/Conditions/HighBloodPressure/Prevention-TreatmentofHighBloodPressure/Managing-Blood-Pressure-with-a-Heart-Healthy-Diet_UCM_301879_Article.jsp

Basile J, Bloch MJ. Overview of hyperten-sion in adults. Last updated November 18,2014. http://uptodate.com/contents/overview-of-hypertension-in-adults?source=search_result&search=hypertension&selectedTitle=1%7E150.

Bellucci A. Reactions to the hemodialysismembrane. Last updated July 29, 2013.www.uptodate.com/contents/reactions-to-the-hemodialysis-membrane


Bosworth H, Olsen M, Grubber J. Two self-management interventions to improve hyper-tension control. Ann Intern Med. 2009;151(10):687-95.

Chobanian AV, Bakris GL, Black HR, et al;National Heart, Lung, and Blood InstituteJoint National Committee on Prevention, De-tection, Evaluation, and Treatment of HighBlood Pressure; National High Blood Pres-sure Education Program Coordinating Com-mittee. The Seventh Report of the Joint Na-tional Committee on Prevention, Detection,Evaluation, and Treatment of High BloodPressure: the JNC 7 report. JAMA. 2003;289(19):2560-72.

DeSimone JA, Beauchamp GK, Drenowski A,et al. Sodium in the food supply: challengesand opportunities. Nutr Rev. 2013;71(1):52-9.

Glasser SP, Judd S, Basile J, et al. Prehyper-tension, racial prevalence and its associationwith risk factors: analysis of the REasons forGeographic And Racial Differences in Stroke(REGARDS) study. Am J Hypertens. 2011;24(2):194-9.

Go AS, Mozaffarian D, Roger VL, et al;American Heart Association Statistics Com-mittee and Stroke Statistics Subcommittee.

Executive summary: heart disease and strokestatistics—2014 update: a report from theAmerican Heart Association. Circulation.2014;129(3):399-410.

James PA, Oparil S, Carter BL, et al. 2014 ev-idence-based guideline for the managementof high blood pressure in adults: report fromthe panel members appointed to the EighthJoint National Committee (JNC 8). JAMA.2014;311:507-20.

Kaplan NM, Victor RG. Kaplan’s Clinical Hy-pertension. 11th ed. Philadelphia: Lippincott,Williams, & Wilkins; 2014.

Kaplan NM. Major side effects and safety ofcalcium channel blockers. Last updated Janu-ary 15, 2015. www.uptodate.com/contents/major-side-effects-and-safety-of-calcium-channel-blockers?source=search_result&search=Major+side+effects+and+safety+of+calcium+channel+blockers.&selectedTitle=1%7E150

Kaplan NM. Use of thiazide diuretics in pa-tients with primary (essential) hypertension.Last updated December 16, 2014. www.up-todate.com/contents/use-of-thiazide-diuretics-in-patients-with-primary-essential-hypertension

Li C, Balluz LS, Ford ES, et al. A comparisonof prevalence estimates for selected healthindicators and chronic diseases or conditionsfrom the Behavioral Risk Factor SurveillanceSystem, the National Health Interview Survey,and the National Health and Nutrition Exami-nation Survey. Prev Med. 2012;54(6):381-7.

Palatini P, Mos L, Santonastaso M, et al. Pre-menopausal women have increased risk ofhypertensive target organ damage comparedwith men of similar age. J Womens Health(Larchmt). 2011;20(8):1175-81.

Yano Y, Fujimoto S, Sato Y, et al. Associationbetween prehypertension and chronic kid-ney disease in the Japanese general popula-tion. Kidney Int. 2012;81(3):293-9.

Terri Townsend is a medical-surgical nursing staffeducator at Community Hospital in Anderson,Indiana. Pamela Anderson is an adult nursepractitioner in peripheral vascular surgery at St.Vincent Medical Group in Indianapolis, Indiana.


Please mark the correct answeronline.

1. Your patient’s blood pressure is 135/88mm Hg, which places him in which stage ofhypertension?

a. Prehypertensionb. Stage 1 hypertensionc. Stage 2 hypertensiond. Hypertensive crisis

2. You check your patient in acute kidneyfailure and find her blood pressure is 180/124mm Hg. This places her in which stage ofhypertension?

a. Prehypertensionb. Stage 1 hypertensionc. Stage 2 hypertensiond. Hypertensive crisis

3. Which of the following hypertension riskfactors cannot be modified?

a. High-sodium dietb. Both parents with hypertensionc. Lack of physical activityd. Excessive alcohol intake

4. Which statement about cardiovascularcomplications of hypertension is correct?

a. Right ventricular hypertrophy is acommon complication.

b. Patients with such complicationscommonly have a shortened QT interval.

c. Left ventricular hypertrophy increases thelikelihood of myocardial ischemia.

d. Patients who experience myocardialinfarction rarely have hypertension.

5. Which statement about neurovascularcomplications of hypertension is correct?

a. Hypertension is the most common causeof nontraumatic intracerebralhemorrhage in adults.

b. Hypertension typically is not apreventable cause of ischemic stroke inadults.

c. Vessels involved in a nontraumaticintracerebral hemorrhage are therecessive arteries.

d. The carotid arteries and aortic arch arenot affected by the presence ofhypertension.

6. Which statement about hypertension andAfrican Americans is correct?

a. Hypertension in African Americans tendsto start at an older age than in otherracial groups.

b. Hypertensive African Americans have afourfold risk of fatal stroke.

c. Hypertensive African Americans have a2.2 greater risk of end-stage renal disease.

d. African Americans have the highestprevalence of hypertension in the world.

7. The blood pressure goal for the generalpopulation younger than age 60 is:

a. systolic below 135 mm Hg, diastolicbelow 80 mm Hg.

b. systolic below 140 mm Hg, diastolicbelow 90 mm Hg.

c. systolic below 140 mm Hg, diastolicbelow 80 mm Hg.

d. systolic below 150 mm Hg, diastolicbelow 90 mm Hg.

8. Which statement about diet and bloodpressure is correct?

a. The DASH diet (Dietary Approaches toStop Hypertension) is low in sweets, redmeat, and saturated fats.

b. The DASH diet can lower systolic bloodpressure an average of 15 mm.

c. Current recommendations for sodiumintake range from 2,000 to 5,000 mg/day.

d. Current recommendations for sodiumintake range from 1,000 to 2,000 mg/day.

9. Which of the following is a first-lineantihypertensive drug category?

a. Aldosterone antagonistsb. Direct vasodilatorsc. Angiotensin-converting enzymeinhibitors

d. Beta blockers

10. The nurse practitioner orders a calciumchannel blocker for your patient withhypertension that hasn’t responded tolifestyle changes. Which statement about thisclass of drugs is accurate?

a. One category of calcium channelblockers is dihydropyridines, which arepotent vasoconstrictors.

b. Drinking grapefruit juice can increasemedication levels in the blood, causing amore pronounced antihypertensiveeffect.

c. Drinking grapefruit juice can decreasemedication levels in the blood, causing adecreased antihypertensive effect.

d. One category of calcium channelblockers is non-dihydropyridines, whichare potent vasodilators.

11. Which statement about angiotensin-converting enzyme inhibitors is true?

a. They lower blood pressure primarily byreducing angiotensin II.

b. They adversely affect cholesterol andglucose levels.

c. They are not prescribed for the treatmentof heart failure.

d. They increase breakdown of kinins in thebloodstream.

12. The physician has ordered captopril foryour patient with hypertension. You knowthat this drug can cause:

a. neutropenia.b. neturophilia.c. thrombocythemia.d. polycythemia.

13. Which statement about angiotensin IIreceptor blockers is correct?

a. They can cause paradoxical hypertension.b. They are not contraindicated in pregnantpatients.

c. They affect bradykinin levels.d. They can cause acute renal failure.

14. An example of later-line drug therapy forhypertension is:

a. irbesartan.b. diltiazem ER.c. furosemide.d. lisinopril.

POST-TEST • What goes up must come down: Hypertension and the JNC-8 guidelines Earn contact hour credit online at http://www.americannursetoday.com/continuing-education/

Provider accreditationThe American Nurses Association’s Center for Continuing Educationand Professional Development is accredited as a provider of contin-uing nursing education by the American Nurses Credentialing Cen-ter’s Commission on Accreditation. ANCC Provider Number 0023. Contact hours: 1.22

ANA’s Center for Continuing Education and Professional Develop-ment is approved by the California Board of Registered Nursing,Provider Number CEP6178 for 1.47 contact hours.

Post-test passing score is 75%. Expiration: 6/1/18

ANA Center for Continuing Education and Professional Develop-ment’s accredited provider status refers only to CNE activities anddoes not imply that there is real or implied endorsement of anyproduct, service, or company referred to in this activity nor of anycompany subsidizing costs related to the activity. The planners andauthor of this CNE activity have disclosed no relevant financial rela-tionships with any commercial companies pertaining to this CNE.

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what goes up must come down: hypertension and the jnc-8 ......hypertension and the jnc-8 guidelines...

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