The nurse is caring for a client with an acute ischemic stroke who has a blood pressure of 178/95 mm Hg. The health care provider prescribes as-needed antihypertensives to be given if the systolic pressure is 200 mm Hg. Which action by the nurse is most appropriate?

Question

The nurse is caring for a client with an acute ischemic stroke who has a blood pressure of 178/95 mm Hg. The health care provider prescribes as-needed antihypertensives to be given if the systolic pressure is >200 mm Hg. Which action by the nurse is most appropriate?

Quizplus · Accepted Answer

An ischemic stroke is a loss of brain tissue perfusion due to blockage in blood flow. Elevated blood pressure is common and permitted after a stroke and may be a compensatory mechanism to maintain cerebral perfusion distal to the area of blockage. This permissive hypertension usually autocorrects within 24-48 hours and does not require treatment unless the hypertension is extreme (systolic blood pressure >220 mm Hg or diastolic blood pressure >120 mm Hg) or contraindicated due to the presence of another illness requiring strict blood pressure control (eg, active ischemic coronary disease, heart failure, aortic dissection). A blood pressure of 178/95 mm Hg should be monitored, along with the client's other vital signs and status (Option B). (Option A) The elevated blood pressure may be a protective measure to ensure tissue perfusion; therefore, the antihypertensive drug should not be given unless indicated by the prescription parameters. (Options C and D) The as-needed prescription is appropriate in this case, so there is no reason to question it and call the health care provider. Educational objective: Elevated blood pressure in the presence of an acute ischemic stroke is an expected finding and may be a protective measure to maintain tissue perfusion.

The Nurse Is Caring for a Client with an Acute