HESI MED SURG / MED SURG 55
QUESTIONS RN V1 (MOST
ANSWER(S))
1. A patient with a history of hypertension treated with a diuretic and an angiotensin-converting enzyme (ACE)
inhibitor arrives in the emergency department complaining of a severe headache and nausea and has a blood
pressure (BP) of 238/118 mm Hg. Which question should the nurse ask to follow up on these findings?
a. “Have you recently taken any antihistamines?”
b. “Have you consistently taken your medications?”
c. “Did you take any acetaminophen (Tylenol) today?”
d. “Have there been recent stressful events in your life?”
ANS: B
Sudden withdrawal of antihypertensive medications can cause rebound hypertension and hypertensive crisis.
Although many over-the-counter medications can cause hypertension, antihistamines and acetaminophen do
not increase BP. Stressful events will increase BP but not usually to the level seen in this patient.
2. The nurse is assessing a patient who has been admitted to the intensive care unit (ICU) with a hypertensive
emergency. Which finding is most important to report to the health care provider?
a. Urine output over 8 hours is 250 mL less than the fluid intake.
b. The patient cannot move the left arm and leg when asked to do so.
c. Tremors are noted in the fingers when the patient extends the arms.
d. The patient complains of a headache with pain at level 7 of 10 (0 to 10 scale).
ANS: B
The patient’s inability to move the left arm and leg indicates that a stroke may be occurring and will require
immediate action to prevent further neurologic damage. The other clinical manifestations are also likely caused
by the hypertension and will require rapid nursing actions, but they do not require action as urgently as the
neurologic changes.
3. A patient with hypertension who has just started taking atenolol (Tenormin) returns to the health clinic after 2
weeks for a follow-up visit. The blood pressure (BP) is unchanged from the previous visit. Which action
should the nurse take first?
a. Tell the patient why a change in drug dosage is needed.
b. Ask the patient if the medication is being taken as prescribed.
c. Inform the patient that multiple drugs are often needed to treat hypertension.
d. Question the patient regarding any lifestyle changes made to help control BP.
ANS: B
Because nonadherence with antihypertensive therapy is common, the nurse’s initial action should be to
determine whether the patient is taking the atenolol as prescribed. The other actions also may be implemented,
but these would be done after assessing patient adherence with the prescribed therapy.
QUESTIONS RN V1 (MOST
ANSWER(S))
1. A patient with a history of hypertension treated with a diuretic and an angiotensin-converting enzyme (ACE)
inhibitor arrives in the emergency department complaining of a severe headache and nausea and has a blood
pressure (BP) of 238/118 mm Hg. Which question should the nurse ask to follow up on these findings?
a. “Have you recently taken any antihistamines?”
b. “Have you consistently taken your medications?”
c. “Did you take any acetaminophen (Tylenol) today?”
d. “Have there been recent stressful events in your life?”
ANS: B
Sudden withdrawal of antihypertensive medications can cause rebound hypertension and hypertensive crisis.
Although many over-the-counter medications can cause hypertension, antihistamines and acetaminophen do
not increase BP. Stressful events will increase BP but not usually to the level seen in this patient.
2. The nurse is assessing a patient who has been admitted to the intensive care unit (ICU) with a hypertensive
emergency. Which finding is most important to report to the health care provider?
a. Urine output over 8 hours is 250 mL less than the fluid intake.
b. The patient cannot move the left arm and leg when asked to do so.
c. Tremors are noted in the fingers when the patient extends the arms.
d. The patient complains of a headache with pain at level 7 of 10 (0 to 10 scale).
ANS: B
The patient’s inability to move the left arm and leg indicates that a stroke may be occurring and will require
immediate action to prevent further neurologic damage. The other clinical manifestations are also likely caused
by the hypertension and will require rapid nursing actions, but they do not require action as urgently as the
neurologic changes.
3. A patient with hypertension who has just started taking atenolol (Tenormin) returns to the health clinic after 2
weeks for a follow-up visit. The blood pressure (BP) is unchanged from the previous visit. Which action
should the nurse take first?
a. Tell the patient why a change in drug dosage is needed.
b. Ask the patient if the medication is being taken as prescribed.
c. Inform the patient that multiple drugs are often needed to treat hypertension.
d. Question the patient regarding any lifestyle changes made to help control BP.
ANS: B
Because nonadherence with antihypertensive therapy is common, the nurse’s initial action should be to
determine whether the patient is taking the atenolol as prescribed. The other actions also may be implemented,
but these would be done after assessing patient adherence with the prescribed therapy.
