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 PR interval, which is the time from the onset of atrial depolarization (beginning of the P wave) to the onset of ventricular depolarization (beginning of the QRS complex), normally ranges from 0.12 to 0.20 seconds. A PR interval of 0.15 second is within the normal range and does not indicate an acute myocardial infarction.

Choice B reason: The QT interval represents the total time for ventricular depolarization and repolarization. The normal QT interval varies based on heart rate and gender but is typically less than half of the R-R interval in a normal heart rhythm. Therefore, a QT interval equal to the R-R interval is abnormally prolonged, which may suggest other conditions but is not a specific indicator of acute myocardial infarction.

Choice C reason: The QRS complex reflects ventricular depolarization and normally ranges from 0.06 to 0.10 seconds. A QRS interval of 0.08 second is within the normal range and does not suggest an acute myocardial infarction.

Choice D reason: ST segment elevation is a critical finding in the diagnosis of acute myocardial infarction. The ST segment should be at the isoelectric line; elevation above this line is indicative of myocardial injury and is a key diagnostic criterion for ST-elevation myocardial infarction (STEMI). An elevated ST segment is often seen in the early stages of an acute myocardial infarction and requires immediate medical attention.

A. The frequency in which blood pressure is taken. B. Interventions implemented in response to a high blood pressure reading. C. The patient's response to interventions implemented. D. The person who obtained the blood pressure reading. E. The site where the blood pressure was obtained.

Correct Answer is A

Explanation

Choice A reason : Hepatomegaly, or the enlargement of the liver, is a common finding in right-sided heart failure. This condition occurs because the heart does not pump blood effectively, leading to congestion and increased pressure in the venous system, including the hepatic veins. As a result, the liver becomes engorged with blood, causing it to enlarge. The normal liver span in adults is about 10-12 cm in the midclavicular line, and any measurement above this can indicate hepatomegaly.

Choice B reason : Orthopnea, which is shortness of breath while lying flat, is more commonly associated with left-sided heart failure. In right-sided heart failure, symptoms are more related to systemic congestion, such as swelling in the legs and abdomen, rather than pulmonary symptoms like orthopnea.

Choice C reason : Dyspnea, or difficulty breathing, can be a symptom of both left and right-sided heart failure. However, in the context of right-sided heart failure, dyspnea is usually due to the accumulation of fluid in the abdominal cavity (ascites) and the increased pressure in the abdominal veins, which can compress the diaphragm and make breathing difficult.

Choice D reason : Frothy sputum is typically not a symptom of right-sided heart failure. It is more indicative of pulmonary edema, which is associated with left-sided heart failure. In right-sided heart failure, the primary issues are related to the systemic circulation and venous congestion.

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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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