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HESI case study - Hypertension - George Thomas

Terms in this set (31)

George's blood pressure reading is 189/110 mmHg. 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 nurse respond?
Please sit here quietly for a few minutes. I need to recheck your blood pressure.

George'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 factors for hypertension does the student nurse identify for George, according to this health history?
Select all that apply
What significant risk factors for hypertension does the student nurse identify for George, according to this health history?

Family history of diabetes.

Alcohol consumption.

Smoking.

Stress.

Caffeine intake.
Alcohol consumption.
Excessive alcohol intake is strongly associated with hypertension.

Smoking.
Tobacco use is a risk factor for hypertension.

Stress.
High levels of stress can lead to an increase in blood pressure.
According to the assessment of this client, which recommendation is most important for the student nurse to provide to George?
See his HCP as soon as possible within the next week for a BP recheck.

George's blood pressure is significantly elevated. Since these BP readings were obtained on the same day, George needs to see his HCP soon for a second BP measurement so that a diagnosis can be determined and treatment initiated.
Which is the best response the student nurse can give to the George about the urgent need to see his HCP?
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, George has an appointment with his HCP. After the exam, the HCP explains to George that he has stage 2, primary (essential) hypertension.

Which information obtained during the assessment supports this diagnosis?
Blood pressure of 184/98 mmHg.

Stage 2 hypertension is described as a systolic blood pressure of greater than or equal to 160 mmHg or a diastolic blood pressure of greater than or equal to 100 mmHg.
How should the nurse respond to George's question?
"90 to 95% of all cases of hypertension are without an identified cause, so unless there is some indicator in your health history, the HCP does not look for one."

Primary (essential) hypertension has no identifiable cause, even though there are several known contributing factors.
While evaluating George's understanding, which statements indicate that George understands the nurse's instructions about his medications?
Select all that apply
While evaluating George's understanding, which statements indicate that George understands the nurse's instructions about his medications?

"I will need to take Diuril early in the day."

"I will be taking these medications for the rest of my life."

"I can expect my heart rate to increase as my blood pressure goes down."

"I may experience impotence with this drug regimen."

"An irritating cough often develops but will subside in a few days."

"I should avoid drinking alcohol."
Case Study Details
"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.


"I should avoid drinking alcohol."
Alcohol may increase the chance of dizziness occurring.
Case Study Details
When discussing these lifestyle modifications with George, what information is most important for the nurse to share?
Use of tobacco products is linked with increased risk for cardiovascular disease.

Discontinuation of tobacco use decreases blood pressure and has cardiovascular benefits within the first year of quitting.
George expresses interest in learning 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 lifestyle.
How should the nurse respond?
Many methods can help reduce stress. Tell me about your work day.

With this response, the nurse helps George identify strategies that might fit into his lifestyle. This response empowers the client to be engaged in the process of determining which strategy will be most effective for him.
George 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 George be successful this time?
Encourage George to make a quit plan.

A quit plan, which includes the quit date, 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 ensure success. George's use of the nicotine gum along with a quit plan may increase the potential for success.
George 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. George states that he had an uncle and a 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 George's concern?
Advise him that his HCP may want to do further testing because of his family history.

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.
Considering the overall plan of care, what is the primary reason for the nurse to encourage George to keep his next appointment?
Follow-up measurement of his blood pressure.

George 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.
Discussion of the results of the ultrasound.

INCORRECT:

If the ultrasound indicates the presence of an abdominal aortic aneurysm, George would be called in immediately for a follow-up appointment at that time.

Evaluation of the effectiveness of George's lifestyle changes.

George does need to be evaluated in how he is doing with smoking cessation, stress management, and decreased alcohol consumption, but these changes will make a difference over time. A month later is too soon to determine the effectiveness of these changes.



Scheduling for further diagnostic testing.

The nurse does not know if any further testing will be needed. Since George has been diagnosed with primary hypertension, further tests are not needed to find the cause of the hypertension.
George 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 George about the aneurysm, what information should the nurse include?
Maintaining a normal blood pressure can effectively treat this size of 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.
George's vital signs are T 98.4° F (36.89° C), P 78 beats/min, R 20 breaths/min, and BP 148/90 mmHg. George states he has been feeling fine except that he seems to be more tired than usual and has trouble sleeping. George states that he has cut down to only 1 pack of cigarettes a week and he has signed up to take a class next month on reducing stress.

Which assessment finding is of most concern to the nurse?
Current blood pressure reading of 148/90 mmHg.

George's blood pressure is still hypertensive. With the presence of an abdominal aortic aneurysm (AAA), attaining and maintaining a normal blood pressure is essential.
The nurse asks George if he is limiting his salt intake and he replies 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.

George remains hypertensive. His treatment regimen needs to be reevaluated in order for George to become normotensive.
The HCP adds nifedipine (Procardia) to George's other prescriptions.
What instruction related to this medication is essential for the nurse to provide George?
Avoid eating fresh grapefruit or grapefruit juice.

Grapefruit decreases the effectiveness of nifedipine (Procardia), a calcium channel blocker.
What statement by George 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 1 year."

Step-down therapy is not started until after 1 year of good blood pressure control.


INCORRECT:

"If I quit smoking, eat a low-sodium diet, decrease my alcohol intake, and get my stress level down, I can quit taking these medications."
Rebound hypertension can occur with sudden discontinuation of many antihypertensives. Discontinuation of these medications should be done under the direction of his healthcare provider.
Six months later, George's wife takes an overdose of diazepam (Valium) and alcohol. She is brought to the Emergency Department (ED) by the EMS. George arrives a little while later from work. He is obviously upset and very angry. As George is giving information to the registration clerk, he becomes pale and complains of the sudden onset of severe back pain. George is taken to the triage nurse.

Which assessment data obtained during the triage assessment alerts the nurse that George 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.
The HCP suspects that George's aorta is dissecting. Aortic dissection is thought to be caused by a sudden tear in the aortic intima, opening the way for blood to enter the aortic wall. Degeneration of the aortic media may be the primary cause for this condition, with hypertension being an important contributing factor. After examining George, the HCP writes several orders.

Which order should the nurse complete first?
IV of 0.9% Normal Saline (NS) with large bore angiocath.

When a 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 George's blood pressure starts to fall.
What other interventions should the nurse perform prior to sending George to the operating room (OR)?
Select all that apply
What other interventions should the nurse perform prior to sending George to the operating room (OR)?

Begin continuous cardiac monitoring.

Check blood pressure every 2 hours.

Insert a second large bore angiocath if one does not exist.

Accompany George to the bathroom, one last time, so that he can empty his bladder before transfer to the OR.

Monitor neuro status every 4 hours.
Begin continuous cardiac monitoring.

George will need to be assessed for tachycardia and other irregular rhythms.


Insert a second large bore angiocath if one does not exist.

Patent and reliable IV access for fluid or blood administration is essential.

INCORRECT:

Check blood pressure every 2 hours.

Continuous blood pressure monitoring every 15 minutes, or according to protocol, is essential to ensure the desired systolic pressure remains in the range of 100 to 120 mmHg.

Accompany George to the bathroom, one last time, so that he can empty his bladder before transfer to the OR.
George's activity should be restricted at this time and a foley catheter should be inserted unless contraindicated.

Monitor neuro status every 4 hours.
Neuro status, pain assessment, and peripheral vascular assessment should be performed more frequently.
When George returns from radiology where the abdominal CT was performed, the diagnosis of dissecting aortic aneurysm is confirmed. George is informed that he needs immediate surgery. Unfortunately, his wife is intubated and nonresponsive.

Place the nursing actions in numerical order from the first action through the last action.
1. Notify George's children and family.
2. Call report to the operating room staff.
3. Get the surgical consent form signed.
4. Consult a social worker.

It is imperative to follow hospital protocol during this time. A significant number of clients who have surgery to repair a dissecting abdominal aortic aneurysm do not live through the surgery. Mark and his family need time to connect before the surgery, so this is the priority nursing action. Calling the OR should be done immediately after notifying the family, to allow adequate time for OR preparation. The surgeon will then need to inform the client about the procedure and the risks involved, as well as obtain the client's signed consent form. Consulting a social worker to help the family deal with psychosocial issues is important, but it is the last priority.
George is complaining of extreme pain. The HCP prescribes morphine sulfate 8 mg IV push. The available form is a 5 mL container of morphine sulfate labeled 2 mg/mL. How many milliliters should the nurse draw up for one dose? (Enter numeric value only. If rounding is necessary, round to the whole number.)
4
4
2 mg/mL x 4 mL = 8 mg
Which action can be safely delegated to the unlicensed assistive personnel (UAP)?
Document a list of George's personal belongings.

This is the only action listed that does not require the expertise of the nurse.

INCORRECT:

Observe George sign the surgical consent form.
The surgeon is responsible for informing the client about the surgery and a nurse may get the consent signed.

Obtain a full set of vital signs along with a neurological check.
While the UAP may take the client's vital signs, a nurse must perform all assessments. Neurological checks are an important assessment parameter.

Call a report of the client's condition to the surgery staff.
Calling report is the responsibility of the nurse who has the knowledge and expertise to provide the correct information.
Which 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.

INCORRECT:

The vital signs were obtained by an experienced UAP.
This only reflects that the right person was assigned to the task, the first step in the delegation process.

A complete set of vital signs are documented on the chart.
This only indicates that the UAP did get a set of vital signs.

The UAP obtains an accurate set of vital signs.
An accurate set of vital signs indicates the right task was performed, but the last step in the delegation process needs to be completed.
The first unit of PRBCs is available before George goes to the OR. While the nurse is hanging the first unit of blood, George asks if he is going to die. George states that he has never been around anyone who was dying and he is scared of what happens after death.

What is the best response by the nurse?
"This is a frightening experience. Is there someone with whom you would like to talk about your fears?"
The nurse acknowledges George's feelings and addresses the issue.

INCORRECT:

"No one knows if you will live or die. Right now you need to focus on being strong for your children when they arrive."
The nurse is negating the client's feelings with this response.

"There is a real chance you may die from this. Many people do die from a dissecting aneurysm."
This is a true statement, but it is not the best response. The nurse closes the conversation with this statement without offering support.

"Your HCP is the best person to answer your questions about whether or not you will live through the surgery."
This response does not address George's fears about what happens after death and also closes the conversation.
George'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 George died in surgery. One of George'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 George'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.

INCORRECT:

Notify the hospital's sentinel event committee.
Sentinel events are occurrences where a mistake made results in harm to a client. There is no indication at this time that a mistake was made by the healthcare team.

Assist the family in deciding which funeral home to use.
Deciding on a funeral home is the responsibility of the family and their support network.

Bring the children into surgery to say goodbye to George.
Bringing the family into the operating room to see George may be a task that the nurse does perform, but it is not mandatory.
George's wife has been taken to the intensive care unit (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.

INCORRECT:

Honor their wishes, recognizing that the children know what is best for their mother.
One of the ethical principles guiding nursing practice is veracity. The nurse caring for Mrs. Thomas needs to respond to her questions with honesty.

Tell the children that legally the nurse must inform their mother.
This is not a legal issue.

Call pastoral care to consult with the family.
Calling pastoral care to become involved may be an appropriate nursing action eventually, but another action takes precedence.
The children are adamant that the nurse not tell their mother of their father's death. Meanwhile, George'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.

INCORRECT:

Policy and procedure manual.
This situation cannot be resolved using a policy and procedure manual.

The unit case manager.
The case manager is not the best resource to resolve this conflict.

Mental health services.
Mental health services may need to be consulted at some point, but another resource is more useful to resolve the immediate situation.
George's children, accompanied by their pastor, tell Mrs. Thomas about George's death. After signing a contract with the counselor stating she will not attempt to commit suicide, Mrs. Thomas is released from the hospital. A funeral service for George is held, and Mrs. Thomas continues with outpatient counseling sessions.
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