A nurse is caring for a client who is at risk for a fall because of orthostatic hypotension. Which of the following actions should the nurse take?

Keep all four of the side rails raised on the client's bed.

Check the client every 4 hr to evaluate their need to use the restroom.

Instruct the client to stand in place when beginning ambulation.

Maintain the client's bed at the nurse's waist level.

Answer and Explanation

The Correct Answer is C

A. Keep all four of the side rails raised on the client's bed: Raising all four side rails can increase the risk of injury if the client attempts to climb over them. Full side rails are not a recommended fall-prevention strategy for clients with orthostatic hypotension.

B. Check the client every 4 hr to evaluate their need to use the restroom: Checking every 4 hours may not be frequent enough to prevent falls related to sudden episodes of dizziness or urgency. More proactive measures, such as assisting with ambulation, are safer for clients at risk.

C. Instruct the client to stand in place when beginning ambulation: Having the client stand in place for a few moments allows blood pressure to stabilize before walking, reducing the risk of dizziness and falls caused by orthostatic hypotension. This is a key intervention for fall prevention in at-risk clients.

D. Maintain the client's bed at the nurse's waist level: The bed height should be adjusted to facilitate safe transfers, typically at the level that allows feet to touch the floor and promotes stability. Keeping the bed at the nurse's waist level does not specifically prevent falls due to orthostatic hypotension.

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Correct Answer is ["B","C","D"]

Explanation

A. Osteoarthritis: Osteoarthritis affects joint function and mobility but does not directly increase the risk for heart failure. While it can limit physical activity, it is not a primary cardiovascular risk factor.

B. Alcohol use disorder: Chronic excessive alcohol consumption can lead to cardiomyopathy, hypertension, and arrhythmias, all of which increase the risk for heart failure. Alcohol use disorder is a well-established modifiable risk factor for cardiac dysfunction.

C. Sleep apnea: Obstructive sleep apnea contributes to intermittent hypoxia, sympathetic nervous system activation, and increased blood pressure, all of which can promote the development of heart failure. Screening and management of sleep apnea are important preventive measures.

D. Diabetes mellitus: Diabetes increases the risk of heart failure through mechanisms such as accelerated atherosclerosis, microvascular damage, and diabetic cardiomyopathy. Poor glycemic control further elevates cardiovascular risk.

E. Hypotension: Hypotension, or low blood pressure, does not increase the risk of heart failure; in fact, hypertension is a more significant risk factor. Chronic hypotension can cause other issues, but it is not directly linked to heart failure development.

A. Headache B. Vomiting C. Confusion D. Sedation E. Sweating

Correct Answer is ["A","B","C","E"]

Explanation

A. Headache: Disulfiram causes an aversive reaction when alcohol is consumed, leading to vasodilation and increased acetaldehyde levels. This often results in a severe, throbbing headache as one of the earliest and most common manifestations. The symptom appears quickly after alcohol intake and signals a disulfiram–alcohol interaction.

B. Vomiting: Accumulation of acetaldehyde triggers gastrointestinal distress, including nausea and profuse vomiting. These symptoms occur because the body is unable to metabolize alcohol properly while on disulfiram. Vomiting is a classic indicator that alcohol was consumed after starting therapy.

C. Confusion: Neurological effects such as confusion can develop during a disulfiram–alcohol reaction due to hypotension, decreased cerebral perfusion, and heightened toxin buildup. This change in mental status is especially concerning and suggests significant physiological stress after alcohol ingestion.

D. Sedation: Sedation is not a typical effect of a disulfiram–alcohol reaction. It is more commonly associated with other CNS depressants or alcohol intoxication alone. Because it does not reflect the vasodilatory or metabolic effects produced by disulfiram, it is not a reliable indicator of concurrent alcohol use.

E. Sweating: Sweating results from the sympathetic surge that occurs when acetaldehyde levels rise during a disulfiram–alcohol reaction. Clients may experience flushing, tachycardia, and diaphoresis as part of the acute response. This strongly supports that alcohol was consumed while taking disulfiram.

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A nurse is caring for a client who is at risk for a fall because of orthostatic hypotension. Which of the following actions should the nurse take?

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