When assessing your client, you note a blood pressure (BP) of 205/115. The client has had BP's within normal limits up until this time. The client complains of a sudden onset severe headache. The nurse recognizes this as probable malignant hypertension. What would be the nurse's first action?
A) Give ordered antihypertensive.
B) Notify the physician.
C) Call a code.
D) Wait 15 minutes and reassess the vital signs.

Question

Quizplus · Accepted Answer

The nurse should immediately notify the physician of the client's extremely elevated blood pressure and sudden onset severe headache. Malignant hypertension is a medical emergency and requires immediate intervention, possibly including hospitalization and intravenous medications. Giving an antihypertensive medication without consulting the physician first could be dangerous and potentially worsen the client's condition. Calling a code is not necessary in this situation, as the client is not currently in cardiac arrest or respiratory distress. Waiting 15 minutes and reassessing vital signs could lead to further complications and delay necessary treatment.

When Assessing Your Client, You Note a Blood Pressure (BP)