The nurse is providing care for a client with hypertension. What priority physical assessment does the nurse include in examination of this client?
a. Skin examination for telangiectasia
b. Otoscopic examination of the inner ear
c. Funduscopic examination of the retina
d. Neurologic examination of the cranial nerves
C
The physical examination of a client with hypertension should include examination of the retina because the appearance of the retina is a reliable index of the severity of hypertension. Telangiectasia is caused by permanent dilation of small blood vessels and is not associated with hypertension. No changes in ear or cranial nerves secondary to hypertension are noted.
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