HESI Case Studies – Hypertension

1. Mr. Dunn’s blood pressure reading is 189/110. 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 respond?
Please sit here quietly for a few minutes. I need to recheck your blood pressure.

Rationale: Mr. Dunn’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.

2. What significant risk factor for hypertension does the student nurse identify for Mr. Dunn according to this health history?
Alcohol consumption

Rationale: Excessive alcohol intake is strongly associated with hypertension.

3. According to the assessment of this client, what recommendation is most important for the student nurse to provide Mr. Dunn?
See his healthcare provider within the next week for a BP recheck

Rationale: Mr. Dunn’s blood pressure is significantly elevated. Since these BP readings were obtained on the same day, Mr. Dunn needs to see his healthcare provider soon for a second BP measurement so that a diagnosis can be determined and treatment initiated.

4. The student nurse continues to talk with Mr. Dunn about hypertension. Mr. Dunn states he feels physically and does not see why he needs to see his healthcare provider. How should the student nurse respond?
While often there are no symptoms, high blood pressure does cause damage to many organs
5. What information obtained during the assessment supports this diagnosis (stage 2, primary [essential] hypertension)?
Blood pressure of 184/98

Rationale: Stage 2 hypertension is described as a Systolic blood pressure of greater than or equal to 160 mm Hg or a Diastolic blood pressure of greater than or equal to 100 mm Hg.

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6. He asks, “shouldn’t the healthcare provider find out why I have hypertension?” How should the nurse respond to Mark’s question?
90-95% of all cases of hypertension are without an identified cause, so unless there is some indicator in you health history, the healthcare provider does not look for one

Primary (essential) hypertension has no identifiable cause, even though there are several known contributing factors.

7. In evaluating Mark’s understanding, which statement(s) indicate that Mark understands the nurse’s instructions about his medications?
-I will need to take Diuril early in the day (since it is a diuretic, take it early in the day since later in the day might disrupt client’s sleep)
-I may experience impotence with this drug regimen (common side effect of many antihypertensive meds)
8. In discussing these lifestyle modifications with Mark, what information is most important for the nurse to share with him?
Use of tobacco products is linked with increased risk for cardiovascular disease
9. Mr. Dunn expresses interest in learning more about how to reduce his stress level. How should the nurse respond?
Many methods can reduce stress. Tell me about your work day
10. What is the most effective nursing intervention to help Mark be successful this time?
Encourage Mark to make a quit plan
11. He asks the nurse if high blood pressure causes this problem. How should the nurse respond to Mark’s concern?
Advise him that his healthcare provider may want to do further testing because of his family history
12. Considering the overall plan of care, what is the primary reason for the nurse to encourage Mark to keep his next appointment?
Follow-up measurement of his blood pressure
13. In teaching Mark about the aneurysm, what information should the nurse include?
Maintaining a normal blood pressure can effectively treat this size of aneurysm
14. Which assessment finding is of most concern to the nurse?
Current blood pressure reading of 148/90
15. Which statement by his wife shows she understands a 2-gm sodium diet?
“I’m preparing a variety of fresh vegetables and avoiding processed foods.”
16. Based on the data the nurse has obtained, which nursing diagnosis should be included in the plan of care?
Ineffective health maintenance
17. What instruction related to this medication is essential for the nurse to provide Mark?
Avoid eating fresh grapefruit or grapefruit juice
18. What statement by Mark 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 a year.”
19. What assessment data obtained during the triage assessment alerts the nurse that Mark needs immediate medical evaluation?
History of 3 cm aortic aneurysm and sudden onset of back pain
20. Which prescription should the nurse complete first?
IV of 0.9% Normal Saline with large bore angiocath
21. Place the nursing actions in numerical order from the first action through the last action
1-Notify Mark’s children and family
2-Call report to the operating room staff
3-Get the surgical consent form signed
4-Consult a social worker
22. Which action can be safely delegated to the unlicensed assistive personnel (UAP)?
Document a list of Mark’s personal belongings
23. What result indicates that this task was successfully delegated?
The UAP reports the current vital signs to the nurse
24. Mark asks if he’s going to die. 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?”
25. One of Mark’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
26. In addition to talking with Mark’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
27. 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
28. What resource is most valuable for the nurse to use to resolve this situation?
The hospital ethics committee
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