A charge nurse is reviewing the expected reference range of blood pressure in adult clients with a newly licensed nurse. Which statement should be included?

• A. Hypertension is diagnosed with two elevated measurements on two separate occasions.
• B. "Successive blood pressure measurements of 126 over 78 is classified as stage I hypertension."
• C. "Stage II hypertension is diagnosed when the blood pressure measurement is 132 over 86."
• D. "A blood pressure measurement of 176 over 102 is classified as a hypertensive crisis."

Answer: (A)

Diagnosing hypertension requires confirming elevated blood pressure on more than one occasion. A single high reading can be influenced by factors like recent activity, caffeine, anxiety, or incorrect cuff size, so you don’t label someone as hypertensive after just one measurement. By obtaining two elevated measurements on two separate visits, you ensure the diagnosis reflects persistent hypertension rather than a temporary fluctuation.

The statement that hypertension is diagnosed after two elevated measurements on two separate occasions matches this approach, making it the best choice. The other options misclassify blood pressure based on single readings or thresholds: a reading like 126/78 is not hypertensive, staging thresholds are different from what's described, and a value such as 176/102 does not meet the criteria for a hypertensive crisis (which is typically defined as systolic >180 or diastolic >120, with symptoms or organ involvement).