Question

The nurse has taken a client's blood pressure twice, 10 minutes apart, in the same arm while the client is seated. The nurse records the two blood pressures of 172/104 and 164/98. What is the appropriate nursing action in response to these readings?

1 Refer the client to a nutritionist after providing health teaching about a low-sodium diet.
2 Place the client in a recumbent position and call the paramedics for transport to the hospital.
3 Talk with the client to assess whether there is stress in the client's life and refer to a counseling service.
4 Take the client's blood pressure in the other arm and then schedule a health care practitioner's appointment for as soon as possible.

Answer 1

The most appropriate action based on the options provided would be to measure the blood pressure in the other arm and schedule a healthcare appointment as soon as possible, as the client's readings indicate stage 2 hypertension. (option 4)

Step-by-step explanation:

The appropriate nursing action in response to the client's blood pressure readings of 172/104 and 164/98 should focus on immediate care and was not given as an option amongst your choices. These blood pressure measurements indicate stage 2 hypertension according to the 2017 guidelines provided by the American College of Cardiology and American Heart Association. However, given the provided options, the most appropriate action would be to take the client's blood pressure in the other arm and then schedule a health care practitioner's appointment as soon as possible as any blood pressure reading above 180/120 mm Hg is considered a hypertensive crisis. This scenario might warrant more urgent medical attention, but between the options provided, a prompt appointment is crucial for proper assessment and management.

Regardless, the nurse should also perform immediate nursing interventions such as assessing additional signs and symptoms for target organ damage, reviewing the client's medication and compliance, assessing for other cardiovascular risk factors, and providing patient education on lifestyle modifications and the importance of follow-up care.