Key Points
Nurses analyze cues to determine blood pressure hypotheses.
Criteria to prioritize blood pressure hypotheses include life-threatening, ABCs, acute versus chronic, and, if resolved, would affect other hypotheses.
The overall goal is to return the blood pressure to expected ranges.
Solutions focus on increasing or decreasing blood pressure depending upon the situation.
Question 1 of 4
Which action would the nurse take to obtain patient observation cues to determine blood pressure alterations?
Exactly!
Question the patient.
Review the patient’s blood pressure on the graphic.
Check the patient’s medication record.
Read the patient’s history in the chart.
Question the patient.
Questioning the patient allows the nurse to obtain patient observation cues for blood pressure alterations.
Review the patient’s blood pressure on the graphic.
Reviewing the patient’s blood pressure on the graphic allows the nurse to obtain a medical record cue, not a patient observation cue.
Check the patient’s medication record.
Checking the medication records allows the nurse to obtain a medical record cue, not a patient observation cue.
Read the patient’s history in the chart.
Reading the patient’s history in the chart allows the nurse to obtain a medical record cue, not a patient observation cue.
Question 2 of 4
Match the hypothesis to its pathophysiologic cause.
Exactly!
Hypovolemia and decreased cardiac output
Hypotension
Peripheral vasodilation with no compensation
Postural hypotension
Thickened arteries that reduce compliance
Hypertension
Question 3 of 4
Which patient situation would the nurse assess first?
Exactly!
Absence of breathing
Hypotension
Hypertension
Orthostatic hypotension
Absence of breathing
Absence of breathing is the patient situation to assess first because of the ABCs; breathing is compromised.
Hypotension
Although hypotension is critical, it does not take precedence over breathing because hypotension is a circulation problem.
Hypertension
Although hypertension can be critical, it does not take precedence over breathing because hypertension is a circulation problem.
Orthostatic hypotension
Although orthostatic hypotension is unexpected, it does not take precedence over breathing because orthostatic hypotension is a circulation problem.
Question 4 of 4
Which outcome would the nurse develop for a patient with hypotension?
Exactly!
Patient’s low blood pressure resolves.
Patient’s vital signs will be within expected ranges.
Patient’s blood pressure will return to expected ranges 2 hours after treatment.
Patient will return to previous levels of functioning.
Patient’s low blood pressure resolves.
This is a goal, not an outcome, for hypotension. “Resolves” is not measurable and there is no timeline, making this an inappropriate outcome.
Patient’s vital signs will be within expected ranges.
This is a goal, not an outcome, for hypotension. There is no timeline, making this an inappropriate outcome.
Patient’s blood pressure will return to expected ranges 2 hours after treatment.
This is an outcome because it uses the SMART method: is specific, measurable, achievable, realistic, and timebound.
Patient will return to previous levels of functioning.
This is a goal, not an outcome, for hypotension. There is no timeline, making this an inappropriate outcome.
Leave a Reply