1. A patient diagnosed with hypertension is taking an angiotensin-converting enzyme (ACE)
inhibitor. When planning care, which of the following outcomes would be appropriate for the
patient?
a. BP will be lower than 1
...
1. A patient diagnosed with hypertension is taking an angiotensin-converting enzyme (ACE)
inhibitor. When planning care, which of the following outcomes would be appropriate for the
patient?
a. BP will be lower than 135/85 on all occasions.
b. BP will be normal after 2 to 3 weeks on medication.
c. Patient will not experience dizziness on rising.
d. Urine output will increase to at least 50 mL/hr.
ANS: A
Goals must be clearly stated so that it is easy to evaluate whether they have been met. “BP . . .
lower than 135/85 . . .” is clearly stated and easily evaluated. In contrast, “BP will be normal .
. .” does not clearly state the desired endpoint. Freedom from dizziness on rising is probably
not achievable because ACE inhibitors are vasodilating agents, which may cause vessel
dilation and hypotension, especially when the patient arises from a seated or lying position.
Patients should be warned of this effect. The expected/desired effect of the ACE inhibitor is to
lower the blood pressure; the urine output is minimally relevant in determining that outcome,
if at all.
Difficulty: Difficult
Nursing Process: Planning
Client Need: PHSI
Cognitive Level: Application
Page 979
PTS: 1
2. You are preparing the nursing care plan for a middle-aged patient admitted to the intensive
care unit for an acute myocardial infarction (heart attack). His symptoms include tachycardia,
palpitations, anxiety, jugular vein distention, and fatigue. Which of the following nursing
diagnoses is most appropriate?
a. Decreased Cardiac Output
b. Impaired Tissue Perfusion
c. Impaired Cardiac Contractility
d. Impaired Activity Tolerance
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