The nurse is screening for hypertension at a local health fair.
A community resident has a blood pressure reading of 138/80 mm Hg. What interventions should the nurse implement for this client? Select all that apply.

Answer and explanation

The correct answers are Choices B, C, D, and E.

Choice A rationale

Encouraging the client to “keep doing whatever you are doing” is not an appropriate intervention for a client with a blood pressure reading of 138/80 mm Hg. This blood pressure reading is considered elevated and could indicate pre-hypertension. Therefore, the nurse should assess the client’s lifestyle and other risk factors for hypertension, ask the client about any current antihypertensive medications, obtain another blood pressure reading to verify the first reading, and recommend further evaluation for possible pre-hypertension.

Choice B rationale

Assessing the client’s lifestyle and other risk factors for hypertension is an important intervention for a client with a blood pressure reading of 138/80 mm Hg. Lifestyle factors, such as diet, physical activity, alcohol consumption, and tobacco use, can significantly influence

blood pressure levels. Therefore, the nurse should assess these factors and provide appropriate education and interventions.

Choice C rationale

Asking the client about any current antihypertensive medications is an important intervention for a client with a blood pressure reading of 138/80 mm Hg. The client may be taking medications that could affect their blood pressure. Therefore, the nurse should ask about these medications and consider their potential impact on the client’s blood pressure.

Choice D rationale

Obtaining another blood pressure reading to verify the first reading is an important intervention for a client with a blood pressure reading of 138/80 mm Hg. Blood pressure can fluctuate throughout the day and can be influenced by various factors, such as stress, physical activity, and caffeine consumption. Therefore, the nurse should obtain another reading to confirm the initial measurement.

Choice E rationale

Recommending further evaluation for possible pre-hypertension is an important intervention for a client with a blood pressure reading of 138/80 mm Hg. A blood pressure reading of 138/80 mm Hg is considered elevated and could indicate pre-hypertension. Therefore, the nurse should recommend further evaluation to confirm this diagnosis and determine appropriate treatment.