Patho Patho #86

Question

The nurse is assessing a client admitted for the treatment of hypertensive urgency. Which finding should be reported to the health care provider immediately?

Answers

  1. An acute change in mental status.
    • Rationale:

      This answer is correct because an acute mental status change indicates that a neurologic insult has occurred due to critically elevated blood pressure and should be immediately reported to the provider.

  2. Blood pressure of 180/98.
    • Rationale:

      This answer choice is not correct because this is an expected finding for a client with a diagnosis of hypertnsive urgency. There is no need to report an expected finding to the provider.

  3. A history of myocardial infarction.
    • Rationale:

      This answer choice is not correct because a history of myocardial infarction is not a priority finding over an acute mental status change. An acute change in mental status indicates a neurologic deficit and should be immediately assessed and addressed.

  4. Clear, yellow urine noted in the urinal
    • Rationale:

      This answer choice is not correct because clear, yellow urine is an indicator of kidneys that are functioning properly.

Overview

The focus of this question is asking the nurse to identify the most critical finding in a client with a diagnosis of hypertensive urgency. Hypertensive urgency is a clinical situation when blood pressure exceeds 180 mmHg systolic and/or 120 mmHg. By definition, there is no end organ damage associated with hypertensive urgency so an acute change in mental status signals an acute decline in the client’s status and therefore requires immediate assessment and intervention.

Explanation

Learning Outcomes

Hypertensive urgency is a condition when blood pressure is significantly elevated, 180/120 mmHg, without evidence of target organ damage. Manifestations that target organ damage has occurred include pulmonary edema, signs of cardiac ischemia, acute renal injury, and/or acute mental status change. A change in mental status indicates a potential cerebral vascular accident and this manifestation should be reported to the provider immediately.

Test Taking Tip

When choosing findings that are “critical” and need to be reported to the provider, changes in mental status almost always fall into this category. A change in level of consciousness is the most sensitive indicator of overall neurologic status.

Video Rationale