Which of the following describes a situation in which the blood pressure is severely elevated and there is evidence of actual target organ damage?
Secondary hypertension
Hypertensive urgency
Hypertensive emergency
Primary hypertension
The Correct Answer is C
Rationale:
A. Secondary hypertension is high blood pressure due to an identifiable cause, such as renal disease, but it does not describe an acute situation with target organ damage.
B. Hypertensive urgency is a situation where the blood pressure is severely elevated but without evidence of target organ damage.
C. Hypertensive emergency is characterized by severely elevated blood pressure with evidence of acute target organ damage, such as encephalopathy, myocardial infarction, or renal failure, requiring immediate medical intervention.
D. Primary hypertension, also known as essential hypertension, is high blood pressure without a known secondary cause and does not describe an acute emergency.
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Correct Answer is D
Explanation
Rationale:
A. Documentation of waveform values is important but does not directly enhance patient safety during monitoring.
B. Limiting the pressure tubing length can help maintain accuracy, but it is not the primary safety measure.
C. Zero referencing is crucial for accurate readings, but it must be done in conjunction with ensuring alarms are active.
D. Ensuring that alarm limits are turned on and appropriately set is the best safety measure to immediately alert the nurse to any critical changes in the patient's status.
Correct Answer is C
Explanation
Rationale:
A. Quickly removing the family members may add to their distress and does not respect their right to decide.
B. Telling them it will be stressful assumes their reaction without giving them a choice.
C. Allowing the family members to choose whether to stay respects their autonomy and can provide comfort during a difficult time. It is also in line with current best practices for family presence during resuscitation.
D. Assigning a staff member to wait outside is appropriate but should be done after offering the family the option to stay in the room.