An adult patient arrived in the emergency department (ED) with ...

[ericka1]

An adult patient arrived in the emergency department (ED) with minor facial lacerations after a motor vehicle accident and has an initial blood pressure (BP) of 182/94. Which action by the nurse is most appropriate?
 
  a. Start an IV line to administer antihypertensive medications.
  b. Discuss the need for hospital admission to control blood pressure.
  c. Treat the abrasions and discuss the risks associated with hypertension.
  d. Recheck the blood pressure after the patient is stabilized and has received treatment.

Question 2

A female patient who initially came to the clinic with incontinence was recently diagnosed with endometrial cancer.
 
  She is usually well organized and calm but the nurse who is giving her preoperative instructions observes that she is irritable, has difficulty concentrating, and yells at her husband. Which action should the nurse take?
  a. Ask the health care provider for a psychiatric referral.
  b. Focus teaching on preventing postoperative complications.
  c. Try to calm patient and reinforce and repeat teaching about the surgery.
  d. Encourage the patient to have bladder repair at the same time as the hysterectomy.

[Galvarado142]

Answer to Question 1

ANS: D
When a patient experiences an acute stressor, the blood pressure increases. The nurse should plan to recheck the BP after the patient has stabilized and received treatment. This will provide a more accurate indication of the patient's usual blood pressure. Elevated blood pressure that occurs in response to acute stress does not increase the risk for health problems such as stroke, indicate a need for hospitalization, or indicate a need for IV antihypertensive medications.

Answer to Question 2

ANS: C
Since behavioral responses to stress include temporary changes such as irritability, changes in memory, and poor concentration, patient teaching will need to be repeated. It is also important to try to calm the patient by listening to her concerns and fears. Psychiatric referral will not necessarily be needed for her, but that can better be evaluated after surgery. Focusing on postoperative care does not address the need for preoperative instruction such as the procedure, NPO instructions before surgery, date and time of surgery, medications to be taken and/or discontinued before surgery, etc. The issue of incontinence is not immediately relevant in the discussion of preoperative teaching for her hysterectomy.

[ericka1]

TYSM

[sailorcrescent]

Excellent