Question

a client with hypertension being seen for follow-up care has a blood pressure of 160/100 mm hg. the client reports following the treatment regimen closely and that blood pressure readings have been elevated for the last 2 weeks. what is the nurses most appropriate action?

report the findings to the health care provider for further plans.
reinforce the instructions for the treatment regimen to the client.
interview the family to determine if the client is giving accurate information.
inform the client that the blood pressure medication will have to be changed.

Explanation:

Analyze the client's clinical presentation

Using the Nursing Assessment knowledge point, the client presents with a significantly elevated blood pressure of \(160/100\text{ mm Hg}\) despite reporting strict adherence to their prescribed treatment regimen for the past 2 weeks. This indicates that the current therapeutic plan is ineffective.

Evaluate the nurse's scope of practice

Using the Priority Nursing Interventions knowledge point, the nurse must identify the most appropriate action within their professional scope. The nurse cannot independently alter or prescribe medications, which rules out telling the client that their medication will definitely be changed.

Determine the priority intervention

Because the client is already adherent and the treatment is failing, the nurse must collaborate with the prescribing clinician. Reporting these clinical findings to the healthcare provider is the essential next step to facilitate a medical review and potential adjustment of the treatment plan.

Answer:

• Report the findings to the health care provider for further plans. (Correct answer)
• Reinforce the instructions for the treatment regimen to the client.
• Interview the family to determine if the client is giving accurate information.
• Inform the client that the blood pressure medication will have to be changed.