Question

In a hypertensive crisis (BP 254/139), what action should the nurse take first?

a) Administer nitroglycerin
b) Initiate intravenous fluids
c) Administer antihypertensive medication
d) Assess for signs of end-organ damage

Answer 1

In a hypertensive crisis, the nurse's first action should be to assess for signs of end-organ damage. After assessing, other treatments like antihypertensive medications may be considered based on the patient's condition.

Step-by-step explanation:

In a hypertensive crisis with blood pressure readings as high as 254/139, the first action that should be taken by a nurse is d) Assess for signs of end-organ damage. This is vital to determine the urgency and type of treatment required. Options such as administering antihypertensive medication or nitroglycerin come into play only after a thorough assessment to rule out complications like heart attack, stroke, kidney damage, etc. Immediate intervention is crucial, but it should be based on a proper evaluation of the patient's condition.

As for the provided reference questions:

1. Angiotensin II is a vasoconstrictor, meaning the correct answer to question 23 is d) angiotensin II.
2. A patient with a blood pressure reading of 70/45, confusion, and complaints of thirst might be experiencing shock or severe dehydration, conditions that require urgent medical attention.