The primary care nurse measures the client's blood pressure and obtains 145/90 mm Hg. Which should the nurse implement?

Question

1. Collaborate on antihypertensive therapy.
2. Ask client about caffeine and sodium intake.
3. Ask for date of initial hypertension diagnosis.
4. Repeat the blood pressure after client relaxation.

Answer 1

4
4. Hypertension is never diagnosed on the basis of one reading. At a minimum, the nurse allows the client to relax for a few minutes and then takes another blood pres-sure measurement. The client is directed to return to the clinic in 1 to 4 weeks to rule out hypertension.
1. Collaborating on antihypertensive therapy is premature because hypertension has not been diagnosed.
2. Asking the client about sodium and caffeine intake is a reasonable response after repeating the blood pressure measurement and obtaining similar results. While in-structing the client to return to the clinic to reevaluate the blood pressure, the provider can suggest lifestyle changes to the client as initial antihypertensive therapy including sodium and caffeine restrictions because sodium retains water and caffeine vasoconstricts.
3. Asking for the date when hypertension was originally diagnosed is premature; however, the nurse conducts a thorough review of the systems by asking about med-ical history and current medications because that information will provide valuable data about the client's blood pressure.