Question

A nurse in an emergency department is admitting a client who reports experiencing a headache and heart palpitations after having a glass of wine 1 hr ago. The client has a history of depresion and a blood pressure of 210/105 mm Hg and a temperature of 39.9 C (103.8 F). Which of the following actions should the nurse take first?

Answer 1

The nurse should first address the most life-threatening conditions when admitting a client in hypertensive crisis and hyperpyrexia. The priority is to lower the extremely high blood pressure to prevent organ damage.

Step-by-step explanation:

The immediate action a nurse should take when admitting a client with a reported headache, heart palpitations after consuming wine, a history of depression, and vital signs indicating hypertensive crisis (blood pressure of 210/105 mm Hg) and hyperpyrexia (temperature of 39.9 C/103.8 F) is to address the most life-threatening conditions first. In this scenario, both the extremely high blood pressure and the high fever are concerning, but given the potential for organ damage, a hypertensive crisis represented by the blood pressure of 210/105 mm Hg warrants the most urgent assessment and intervention. The nurse should initiate measures to lower the blood pressure cautiously and seek immediate medical treatment to prevent complications such as stroke, heart attack, or kidney failure.