Question

After you welcome and help Mrs. Nelson settle into her new room on your unit, she enjoys visiting with friends then takes an hour-long nap. Upon awakening with a startled feeling, unsure where she is, you take her vital signs and discover a blood pressure of 146/94 mmHg. When documenting this information, which describes your nursing assessment?

1) Client has signs of hypotension. Will educate client to increase fluid intake and recheck in one hour.
2) Client has symptoms of orthostatic hypotension; educated to call for assistance with ambulating.
3) Client's blood pressure within expected limits. Will reevaluate in 4 hours.
4) Client is currently hypertensive. Will reassess blood pressure in 15 minutes.

Answer 1

Mrs. Nelson's blood pressure of 146/94 mmHg indicates that she is hypertensive. The nursing assessment should be option 4, reassessing her blood pressure in 15 minutes.

Step-by-step explanation:

The correct nursing assessment for Mrs. Nelson, who has a blood pressure of 146/94 mmHg, is that the client is currently hypertensive. This assessment would correspond to option 4 from the provided choices, as this blood pressure measurement is above the normal range and indicative of hypertension, not hypotension. The nursing action would involve reassessing Mrs. Nelson's blood pressure in 15 minutes to monitor and manage her hypertension appropriately.