When auscultating the blood pressure of a 25-year-old, the nurse hears the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg the Korotkoff sounds muffle. At 92 mm Hg the Korotkoff sounds disappear. How should the nurse record this patient's blood pressure?

A. Falsely low. Using an adult-sized cuff on a child results in an overestimation of the cuff size, causing the cuff to not inflate properly and distribute less pressure, leading to a falsely low blood pressure reading.
B. Indistinct. The reading may be inaccurate, but it will still produce a numerical value rather than being completely indistinct.
C. Accurate. Accuracy depends on using a cuff size appropriate for the child's arm circumference. An adult cuff on a child is too large, leading to an incorrect reading.
D. Falsely high. A too-small cuff would produce a falsely high reading, but an oversized cuff produces a falsely low blood pressure.

A. Inform the patient's health care provider immediately to obtain an order for antihypertensive medications. While notifying the provider may be necessary, the nurse must first confirm the accuracy of the blood pressure reading before taking further action.
B. Instruct the nursing assistant to take the patient's blood pressure again and inform the nurse of the results immediately. Nursing assistants can take blood pressure readings, but the nurse should personally verify a critically high reading using a manual method.
C. Take the patient's blood pressure manually with a sphygmomanometer and stethoscope. Electronic monitors can sometimes give false readings, especially in patients with irregular heartbeats or movement. Manually verifying ensures an accurate assessment before determining further action.
D. Perform a neurological assessment to determine if the patient is stressed, in pain, or having a stroke. A neurological assessment is important if the elevated BP is confirmed, but the first priority is verifying the reading manually.