The client draws back when the nurse reaches over the side rails to take his blood pressure. What should the nurse do?

• A. Presume the patient does not want the measurement and stop
• B. Apologize for straddling the client and explain the need for contact
• C. Resume measurement regardless of patient reaction
• D. Call for assistance before proceeding

Answer: (B)

When a patient pulls away, the essential idea is to respect their autonomy while still obtaining necessary information. Your next move is to acknowledge the intrusion, apologize for crossing over the client, and briefly explain why contact is needed. Blood pressure measurement requires placing a cuff on the arm and inflating it, which involves physical contact; clarifying that the contact is for an accurate reading and patient safety helps the patient understand the purpose and may make them more willing to proceed. If they agree, proceed with the measurement; if they don’t, pause and address concerns or discuss alternatives rather than pressing on. Reserve calling for assistance for situations where there’s safety risk or aggression, not simply for a patient who pulls back.