A nurse is assisting in the plan of care for a client who has dehydration and hypotension. Which of the following actions should the nurse plan to take?

Encourage the client to use guided imagery to relax.

Elevate the head of the client's bed.

Increase the client's fluid intake.

Instruct the client to perform the Valsalva maneuver.

Answer and Explanation

The Correct Answer is C

Choice A reason : Guided imagery is a relaxation technique that can help reduce stress and anxiety, but it does not directly address the physiological issues of dehydration and hypotension. While it may be beneficial as a complementary therapy, it is not the primary intervention for a patient suffering from these conditions.

Choice B reason : Elevating the head of the bed is generally recommended for patients who have difficulty breathing or to prevent aspiration, but it is not the standard care for hypotension. In fact, for a hypotensive patient, elevating the legs might be more beneficial to promote venous return to the heart⁹[^20^].

Choice C reason : Increasing fluid intake is the most direct and effective way to treat dehydration. When a patient is hypotensive, it often indicates a low blood volume, which can be improved by increasing fluid intake. This can be done orally if the patient is conscious and able to drink, or intravenously if they are not. The normal range for blood pressure is 90/60 mmHg to 120/80 mmHg, and maintaining adequate hydration helps to ensure blood pressure stays within this range⁸.

Choice D reason : The Valsalva maneuver is a technique used to potentially correct certain types of abnormal heart rhythms, particularly supraventricular tachycardia, and not for treating hypotension or dehydration. It involves increasing intrathoracic pressure by exhaling forcefully with a closed airway, which can have various effects on the cardiovascular system. However, it is not an appropriate intervention for a dehydrated, hypotensive patient⁹[^10^].

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Correct Answer is D

Explanation

Choice A reason : The statement that the test will be complete in 30 to 60 minutes is incorrect. An ECG is a quick, non-invasive procedure that typically takes only a few minutes to perform.

Choice B reason : The statement about feeling a slight tingling is not accurate for an ECG. This test does not cause any sensations, as it simply records the electrical activity of the heart.

Choice C reason : The mention of radioactivity from dye is not applicable to an ECG. This test does not involve the use of any dyes or radioactive substances. Dyes are typically used in imaging tests like CT scans or MRIs, not ECGs.

Choice D reason : This is the correct statement. For an ECG, electrodes are placed on the patient's chest and extremities to record the electrical activity of the heart. This allows the healthcare provider to assess the heart's rhythm, identify any irregularities, and diagnose conditions.

A. Schedule his next appointment for 1 year from now. B. Provide information for a weight loss plan that includes increasing physical activity. C. Provide information about how to reduce risk factors of hypertension. D. Schedule an appointment for a prostate-specific antigen (PSA) test.

Correct Answer is D

Explanation

Choice A reason: Scheduling the next appointment for 1 year from now is a standard practice for patients who are considered to be in good health and have no immediate medical concerns. Given the patient's normal BP and BMI, along with no reported medical problems, this would typically be an appropriate action. However, it is essential to consider the patient's age and race, as African American men are at a higher risk for certain conditions, such as prostate cancer, which may warrant more frequent monitoring.

Choice B reason: While providing information for a weight loss plan that includes increasing physical activity is generally beneficial, it may not be necessary for this patient. His BMI is 24, which falls within the normal range (18.5-24.9), indicating that he is not overweight. Therefore, unless the patient expresses a desire to lose weight or improve fitness, this action might not be a priority.

Choice C reason:Offering information on reducing risk factors for hypertension is always a positive step in preventive healthcare. However, the patient's BP is 126 mm Hg, which is considered a normal reading (normal BP range is 90/60 mm Hg to 120/80 mm Hg). Therefore, while education on maintaining a healthy lifestyle is valuable, it may not be the most critical action for this visit.

Choice D reason:Scheduling a PSA test is recommended for African American men starting at age 45 due to their increased risk of prostate cancer. The PSA test measures the level of prostate-specific antigen in the blood, which can be an indicator of prostate cancer. Given the patient's demographic, this proactive screening measure is advisable, despite the absence of symptoms or previous medical problems.

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A nurse is assisting in the plan of care for a client who has dehydration and hypotension. Which of the following actions should the nurse plan to take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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