A nurse assesses a client's blood pressure to be 180/68 mm Hg. Earlier in the day, the client's blood pressure was 142/86 mm Hg. What action by the nurse is most appropriate?

Question

Quizplus · Accepted Answer

Systolic hypertension and widened pulse pressure are two of the three signs of Cushing's triad. Earlier in the day the client's pulse pressure was 56 mm Hg and currently it is 112 mm Hg. The nurse would assess the client's heart rate next to determine if he or she is bradycardic; the third sign of Cushing's triad. Pain and anxiety can lead to hypertension, but these assessments are not the priority. The MEND exam is a screening tool for stroke.

A Nurse Assesses a Client's Blood Pressure to Be 180/68