A patient presents with a blood pressure of 160/95 mm Hg during a routine check-up. What is the most appropriate initial nursing intervention?
Recheck the blood pressure after 5 minutes of rest
immediately administer antihypertensive medication
Schedule follow-up in 6 months.
Advise the patient to lower salt intake immediately.
The Correct Answer is A
A. Recheck the blood pressure after 5 minutes of rest: Blood pressure can be temporarily elevated due to stress, activity, or anxiety (“white coat effect”). Reassessing after the patient has rested ensures an accurate measurement before making clinical decisions or initiating treatment.
B. Immediately administer antihypertensive medication: Initiating medication without confirming persistent elevation and evaluating for underlying causes is inappropriate. Accurate assessment is needed before starting therapy.
C. Schedule follow-up in 6 months: Waiting six months without reassessment risks missing persistent hypertension, which can lead to cardiovascular complications. Follow-up should be sooner after confirming the measurement.
D. Advise the patient to lower salt intake immediately: Dietary counseling is important for hypertension management, but it is not the priority initial action. Confirming the elevated blood pressure first guides appropriate interventions.
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Related Questions
Correct Answer is D
Explanation
A. Always carry personal protective equipment in a visible manner: While PPE is important for infection control, displaying it prominently may create fear or imply mistrust. PPE should be used appropriately without compromising rapport or household comfort.
B. Always start the visit by discussing the client's medical history: Beginning with medical history may overlook establishing rapport and respecting the client’s household norms. Initial engagement should prioritize trust, cultural sensitivity, and comfort before detailed health discussions.
C. Request the client to leave the room during the nurse's assessment: Asking the client to leave is unnecessary and may be perceived as disrespectful or intrusive. Assessments should involve the client when appropriate, maintaining privacy and dignity without excluding them unnecessarily.
D. Ask for permission before entering each room in the home: Seeking permission demonstrates respect for the client’s privacy, personal space, and household values. It establishes trust, supports safety, and aligns with culturally sensitive, patient-centered care practices.
Correct Answer is A
Explanation
A. The preferences and values of the client: Evidence-based practice integrates clinical expertise with the best available research and, importantly, the client’s preferences, values, and needs. Considering the client ensures care is individualized, ethical, and more likely to be accepted.
B. The ease of implementation: While practical feasibility is a consideration, it is secondary to ensuring that interventions align with client values and evidence-based recommendations. Ease alone does not justify care decisions.
C. The cost-effectiveness of the intervention: Cost is relevant for resource management, but prioritizing it over client-centered considerations may compromise individualized care and ethical practice.
D. The latest medical trends: New treatments or trends are not inherently evidence-based. Nurses must critically evaluate research quality and applicability rather than following trends without considering effectiveness and client relevance.
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