Difficulty: Medium
Average Score: 68%
Simulated
Passage / Scenario
The following scenario applies to the next 1 itemsThe nurse in the emergency department is caring for a 58-year-old male client.
Item 1 of 1
History & Physical Vital Signs Laboratory
Physician: >
1600: 58-year-old client with a history of hypertension and diabetes mellitus (type one) reports headaches and elevated blood pressure. The client reported the headaches started one day ago and have worsened. The client reports not taking his prescribed medications because he lost his health insurance. His prescribed antihypertensive medications were clonidine and enalapril. The client has a flushed appearance on exam, endorses a generalized headache, and blurred vision.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress.
Correct answer
D,E,F,G
Rationale
The client is likely experiencing a hypertensive emergency due to elevated BP, headache, and blurred vision. Actions: E - Nitroprusside lowers BP rapidly; D - Semi-Fowler's position reduces cardiac workload. Parameters: Blood Pressure monitors treatment efficacy; Thiocyanate levels ensure nitroprusside safety.