HESI Registered Nurse EXIT Practice Exam

In an intensive care unit for hypertensive crisis, what is the priority assessment in the first hour of care?

1. Heart rate

2. Pedal pulses

3. Lung sounds

4. Pupil responses

The correct answer is: Pupil responses

In the context of managing a hypertensive crisis, the most critical assessment in the first hour of care focuses on pupil responses. This is because a hypertensive crisis can lead to significant complications, such as hypertensive encephalopathy or intracranial hemorrhage, which can affect neurological status. Changes in pupil responses can indicate increased intracranial pressure or neurological compromise, making it imperative for the nurse to assess this as part of the initial evaluation. Monitoring pupil responses provides valuable insight into the patient’s neurological function and can help determine if there is any need for immediate intervention. Early detection of altered mental status or changes indicative of increased intracranial pressure can lead to timely treatment, which is essential in preventing further complications. Other assessments, while important in overall patient management, are not the primary focus during the initial hour of care for a patient experiencing a hypertensive crisis. Although heart rate, pedal pulses, and lung sounds can provide crucial information about the patient's cardiovascular and respiratory status, the immediate prioritization should be on neurological function, particularly pupil responsiveness, to gauge the severity and potential complications stemming from the hypertensive crisis.