Question

A nurse is an emergency department is caring for a client who has a BP of 254/139 mm Hg. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first?

a. Administer an antihypertensive medication as prescribed.

b. Place the client in a supine position.

c. Encourage slow, deep breathing.

d. Assess the client's neurologic status.

Answer 1

In the case of a hypertensive crisis, the first action for a nurse is to assess the client's neurologic status. This is crucial for determining immediate care and precedes other interventions such as giving medications, positioning, and breathing exercises.

Step-by-step explanation:

Understanding Hypertensive Crisis and Appropriate Nursing Interventions

A hypertensive crisis is a severe increase in blood pressure that can lead to stroke, heart attack, or other serious health issues if not treated immediately and effectively. When a client exhibits a blood pressure reading of 254/139 mm Hg, it is a medical emergency. The first step a nurse should take is 'd. Assess the client's neurologic status.' This action is vital to determine the presence of any neurologic deficits which may indicate end-organ damage or an ongoing stroke.

Other steps including administering prescribed antihypertensive medication, encouraging slow, deep breathing, and placing the client in a supine position would also be part of the care plan, but after the initial assessment. Quick and accurate assessment of neurologic status can dictate the urgency of interventions and potential need for additional emergent care.

Patients with hypotension (e.g., a BP of 70/45 mm Hg) often present with symptoms such as confusion and thirst, which are indicative of decreased perfusion to organs and a need for immediate intervention to prevent shock and other complications.