The home care nurse is seeing an elderly client whose blood ...

[dakota nelson]

The home care nurse is seeing an elderly client whose blood pressure is 150/100 mmHg. When reviewing medications, the client reports taking the blood pressure medication only when feeling tense. The nurse should instruct the patient to:
 
  1. Continue to take medication when feeling tense.
   2. Contact the physician for an increase in blood pressure medication.
   3. Take the blood pressure medication twice the prescribed dosage for 1 day then resume the daily schedule.
   4. Take the blood pressure medication as prescribed regardless of feeling tense.

Question 2

A client on the psychiatric unit has become highly agitated and is threatening other clients and some of the staff. The nurse escorts the client to the isolation room, leaves the door open, and tells the client:
 
  1. I can't believe you behaved in this manner and upset everyone else...
   2. If you do not calm down, we will sedate you for your own safety..
   3. You scared the other clients and I must now help them..
   4. I'm going to sit right here in case you need to talk..

[Gabe]

Answer to Question 1

4. Take the blood pressure medication as prescribed regardless of feeling tense.

Rationale:
Clients sometimes mistakenly take blood pressure medication only on an as-needed basis. This is incorrect; the client should take the medication as prescribed on a daily basis. The dosage prescribed may be appropriate if taken daily; therefore, it would not need to be increased. To advise the patient to increase the medication without a physician consultation would be out of the scope of nursing practice.

Answer to Question 2

4. I'm going to sit right here in case you need to talk..

Rationale:
The nurse offers support to the client by offering to listen if the client wants to talk about the episode. Telling the client that the nurse does not believe the behavior is not effective communication at this point. Threatening the client with medication is not allowed. The psychiatric client may not be aware enough to realize the impact of behavior on the other clients.

[dakota nelson]

Excellent

[Joy Chen]

TYSM