two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and
he admits that he has not been taking the prescribedmedication because
the drugs make him “feel bad”. In explainingthe need for hypertension
control, the nurse should stress that anelevated BP places the client at risk
for which pathophysiologicalcondition?
a- Blindness secondary to cataracts
b- Acute kidney injury due to glomerular damage
c- Stroke secondary to hemorrhage
d- Heart block due to myocardial damage
Rationale: Stroke related to cerebral hemorrhage is major risk for
uncontrolled hypertension.
• An unlicensed assistive personnel (UAP) assigned to obtain clientvital
signs reports to the charge nurse that a client has a weak pulse with a rate
of 44 beat/ minutes. What action should the charge nurse implement?
a- Instruct the UAP to count the client apical pulse rate for sixtyseconds
b- Determine if the UAP also measured the client‟s capillary refilltime.
c- Assign a practical nurse (LPN) to determine if an apical radialdeficit is
present.
d- Notify the health care provider of the abnormal pulse rate andpulse
volume.
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