An adult patient arrived in the emergency department (ED) with minor facial lacerations after a motor vehicle accident and has an initial blood pressure (BP) of 182/94. Which action by the nurse is most appropriate?
a. Start an IV line to administer antihypertensive medications.
b. Discuss the need for hospital admission to control blood pressure.
c. Treat the abrasions and discuss the risks associated with hypertension.
d. Recheck the blood pressure after the patient is stabilized and has received treatment.
ANS: D
When a patient experiences an acute stressor, the blood pressure increases. The nurse should plan to recheck the BP after the patient has stabilized and received treatment. This will provide a more accurate indication of the patient's usual blood pressure. Elevated blood pressure that occurs in response to acute stress does not increase the risk for health problems such as stroke, indicate a need for hospitalization, or indicate a need for IV antihypertensive medications.
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