A client has been treated for hypertension.
What blood pressure reading indicates to the nurse that the treatment is effective?

Maintain trust and avoid behaviors that may increase agitation. This is because the client is likely experiencing a manic episode, which is characterized by increased activity, rapid speech, and decreased need for sleep. The nurse should use a calm and supportive approach, provide a safe and structured environment, and avoid confrontation or criticism.

Choice B is wrong because ordering the client to go to their room and alerting security would escalate the situation and violate the client’s rights.

Choice C is wrong because telling the client to sit down or risk isolation and loss of privileges would be threatening and punitive, which could increase the client’s agitation and anger.

Choice D is wrong because sedating the client after collecting a lithium level would be premature and inappropriate without a physician’s order and without assessing the client’s vital signs, mental status, and medication history. Lithium is a mood stabilizer that can cause toxicity if the level is too high.

What is your understanding of the situation?”. This is a therapeutic response because it respects the client’s autonomy and invites them to share their concerns and feelings about the surgery.

Choice A is wrong because it is authoritarian and dismissive of the client’s feelings. It does not acknowledge the client’s right to refuse treatment.

Choice C is wrong because it is nontherapeutic and shows agreement with the client’s refusal. It also implies that the nurse and the doctor are on different sides.

Choice D is wrong because it is manipulative and guilt-tripping. It implies that the client does not care about their loved ones or their own life.