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.
A.
Encourage the client to “keep doing whatever you are doing.”.
B.
Assess the client’s lifestyle and other risk factors for hypertension.
C.
Ask the client about any current antihypertensive medications.
D.
Obtain another blood pressure reading to verify the first reading.
E.
Recommend further evaluation for possible pre-hypertension.
The Correct Answer and Explanation is:
he correct answers are:
B. Assess the client’s lifestyle and other risk factors for hypertension.
C. Ask the client about any current antihypertensive medications.
D. Obtain another blood pressure reading to verify the first reading.
E. Recommend further evaluation for possible pre-hypertension.
Explanation:
A blood pressure reading of 138/80 mm Hg falls into the category of elevated blood pressure or pre-hypertension, according to the guidelines established by the American College of Cardiology (ACC) and the American Heart Association (AHA). While it is not classified as hypertension, it indicates that the individual is at increased risk of developing hypertension in the future.
B. Assess the client’s lifestyle and other risk factors for hypertension:
Evaluating the client’s lifestyle is critical. Risk factors for hypertension include diet (especially high salt intake), physical inactivity, smoking, alcohol consumption, stress, and obesity. By understanding the client’s lifestyle, the nurse can help the individual make necessary changes to prevent progression to hypertension.
C. Ask the client about any current antihypertensive medications:
It is essential to determine whether the client is on any antihypertensive medications, as this could affect the blood pressure reading. If the client is already on medication, this reading might indicate a need to adjust the treatment plan. Alternatively, it could suggest medication noncompliance or ineffective therapy.
D. Obtain another blood pressure reading to verify the first reading:
A single elevated reading may not be sufficient to diagnose hypertension or pre-hypertension. Blood pressure can fluctuate due to various factors such as stress, anxiety, or physical activity. Rechecking helps to confirm whether the initial reading was accurate.
E. Recommend further evaluation for possible pre-hypertension:
Pre-hypertension is a critical phase, and recommending further evaluation is necessary to monitor and manage the condition. Preventive measures, such as lifestyle modifications, may help in reducing the risk of developing hypertension.
A. Encourage the client to “keep doing whatever you are doing”:
This option is incorrect because the blood pressure reading is not within the normal range, and ignoring the elevated value may result in the progression to hypertension.