A client with hypovolemia is at risk for orthostatic hypotension. Which of the following interventions should the nurse implement in this client?

Encourage the client to change positions

Encourage the client to exercise vigorously

Encourage the client to stand for extended periods

Encourage the client to limit fluid intake

Answer and Explanation

The Correct Answer is A

A. Encouraging the client to change positions slowly, such as moving from lying to sitting and then to standing, helps to minimize the risk of orthostatic hypotension. This gradual change allows the body to adjust to positional changes without causing a sudden drop in blood pressure.
B. Encouraging vigorous exercise is not recommended for a client with hypovolemia as it could exacerbate the condition, potentially causing dizziness, fainting, or further lowering blood pressure.
C. Encouraging the client to stand for extended periods is not appropriate for a client at risk for orthostatic hypotension, as standing for prolonged periods can cause blood to pool in the lower extremities, increasing the risk of fainting or dizziness.
D. Encouraging the client to limit fluid intake is inappropriate for a client with hypovolemia. Adequate fluid intake is crucial to help restore blood volume and prevent hypotension.

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Correct Answer is C

Explanation

A. The pain does not come from severed blood vessels in the residual stump. Phantom limb pain is not caused by the stump itself but rather by the brain’s perception of the missing limb.
B. Phantom limb pain is not psychosomatic. It is a real phenomenon where the brain continues to receive signals from nerves that were previously connected to the amputated limb.
C. Phantom limb pain is often treated with adjunct medications such as antiepileptics (e.g., gabapentin) and antidepressants (e.g., amitriptyline), which help modify the way the brain processes pain signals.
D. While opioid medications can be used for pain management, phantom limb pain often does not respond well to opioids. It typically requires a combination of other treatments, such as those mentioned in C.

A. Ascending muscle weakness B. Muscle tetany and hyperreflexia C. Poor turgor and dry mucous membranes D. Bradycardia and hypotension

Correct Answer is C

Explanation

A. Ascending muscle weakness is more characteristic of hypokalemia (low potassium levels) rather than hypernatremia.
B. Muscle tetany and hyperreflexia are typically seen in hypocalcemia (low calcium levels) or hypomagnesemia (low magnesium levels), not hypernatremia.
C. Hypernatremia (high sodium levels) commonly causes dehydration, which results in poor skin turgor and dry mucous membranes. This is a key clinical sign of hypernatremia.
D. Bradycardia and hypotension are more commonly associated with hypovolemia (low blood volume) or hypotension, but they are not specific to hypernatremia.

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A client with hypovolemia is at risk for orthostatic hypotension. Which of the following interventions should the nurse implement in this client?

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Naxlex Comprehensive Predictor Exams

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Explanation

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