Question

Initial client assessment information includes blood pressure 160/110 mm Hg, pulse 88 beats/minute, respiratory rate 22 breaths/minute, and reflexes +3/+4 with 2 beat clonus. Urine specimen reveals +3 protein, negative sugar and ketones. Based on these findings, the nurse would expect the client to have which concerns?

Answer 1

Health concerns based on the assessment findings, such as elevated blood pressure, heightened reflexes, and proteinuria, might include hypertensive crisis, preeclampsia, or other kidney disorders that necessitate immediate medical attention.

Step-by-step explanation:

The student's question is asking for the potential health concerns based on certain assessment findings, which include elevated blood pressure (160/110 mm Hg), an increased pulse (88 beats/minute), a slightly elevated respiratory rate (22 breaths/minute), heightened reflexes (+3/+4), and the presence of 2 beat clonus. Additionally, the urine specimen showing +3 protein with negative sugar and ketones. These findings can indicate clinical concerns such as hypertensive crisis, possible preeclampsia if it is a pregnant client due to proteinuria, or potentially other kidney disorders that can give rise to proteinuria and high blood pressure. The positive clonus might suggest central nervous system involvement or severe hypertension that requires immediate medical attention.