A nurse is collecting data from a client who has chronic kidney failure. An assistive personnel reports that the client has a blood pressure of 190/110 mm Hg. Which of the following actions should the nurse take first?

Choice A reason: Guilt-tripping with duty ignores caregiver burden, risking burnout. Scientifically, this lacks support for Alzheimer’s care, as emotional pressure doesn’t address practical needs, potentially worsening family stress and health outcomes contrary to holistic care principles.

Choice B reason: Offering respite care info supports the son, reducing stress with temporary relief options. Scientifically, this aligns with caregiver well-being research, as breaks improve mental health and sustain home care for Alzheimer’s, addressing his needs effectively.

Choice C reason: Suggesting other family help assumes availability, potentially straining dynamics without solutions. Scientifically, this shifts burden without support, less effective than respite, as it doesn’t guarantee aid or address the son’s immediate caregiving capacity.

Choice D reason: Long-term care is a major step, not initial support, and may feel dismissive. Scientifically, it skips intermediate options like respite, which better sustain home care for mild conditions, misaligning with gradual care escalation principles.

Choice A reason: Constipation isn’t a primary effect of disulfiram-alcohol reaction, which causes acetaldehyde buildup, triggering vasodilation and nausea, not gut motility issues. Scientifically, this reaction targets cardiovascular and systemic responses, lacking evidence for significant gastrointestinal stasis as a monitored outcome in this scenario.

Choice B reason: Dry skin isn’t linked to disulfiram-alcohol interaction, which induces flushing and sweating from acetaldehyde toxicity, not dehydration. Scientifically, the reaction affects vascular and autonomic systems, producing moist, not dry, skin responses, making this an unrelated finding for monitoring here.

Choice C reason: Hypotension occurs in disulfiram-alcohol reaction as acetaldehyde dilates vessels, dropping blood pressure. This cardiovascular effect, alongside tachycardia, is a key sign to monitor, aligning with scientific understanding of the drug’s inhibition of aldehyde dehydrogenase, causing systemic distress.

Choice D reason: Urinary retention isn’t a typical disulfiram-alcohol effect; the reaction focuses on vasodilation, nausea, and hypotension from acetaldehyde. Scientifically, autonomic overstimulation may occur, but bladder dysfunction isn’t a primary outcome, making this less critical to monitor than cardiovascular collapse.