A nurse is educating a client who is 60 years old about strategies to prevent orthostatic hypotension. Which of the following instructions should the nurse include?
(Select all that apply.).
Avoid crossing your legs when sitting.
Wear compression stockings.
Drink caffeinated beverages.
Change positions slowly.
Increase your salt intake.
Correct Answer : A,B,D
The correct answer is A, B, and D. These are some of the strategies to prevent orthostatic hypotension, which is a sudden drop in blood pressure caused by a change in posture, such as when a person stands up quickly.
Some explanations for the other choices are:.
• Choice C is wrong because drinking caffeinated beverages can cause dehydration, which can worsen orthostatic hypotension by reducing the fluid volume in the blood vessels.
• Choice E is wrong because increasing salt intake can raise blood pressure, but it can also cause fluid retention, which can strain the heart and kidneys. People with hypertension, heart failure, or kidney disease should limit their salt intake.
Some normal ranges for blood pressure are:.
• Systolic blood pressure (the top number) should be less than 120 mmHg for most adults.
• Diastolic blood pressure (the bottom number) should be less than 80 mmHg for most adults.
• Orthostatic hypotension is diagnosed when there is a drop of 20 mmHg or more in systolic blood pressure or 10 mmHg or more in diastolic blood pressure within 2 to 5 minutes of standing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A.
“I will use a walker until I can walk without pain.” This statement indicates a need for further teaching because the client should use a walker or other assistive device until they have regained their balance, flexibility and strength, not just until the pain subsides.Using a walker too long or too little can affect the healing process and the stability of the new hip joint.
Choice B is correct because the client should avoid crossing their legs or bending their hip more than 90 degrees to prevent dislocating the new hip joint.
Choice C is correct because the client should sleep on their back with a pillow between their legs to keep the hip in a neutral position and prevent excessive internal or external rotation.
Choice D is correct because the client should apply ice to their hip if it becomes swollen or inflamed to reduce pain and inflammation.The client should also elevate their leg and notify their healthcare provider if they notice any signs of infection, such as fever, chills, redness, warmth or drainage from the incision site.
Normal ranges for hip replacement surgery recovery vary depending on the individual and the type of surgery, but some general guidelines are:.
• The client should be able to walk with a cane or crutches within 2 to 4 weeks after surgery.
• The client should be able to resume most daily activities within 6 to 12 weeks after surgery.
• The client should avoid high-impact activities, such as running, jumping or contact sports, for at least 6 months after surgery.
• The client should have regular follow-up visits with their healthcare provider and physical therapist to monitor their progress and adjust their treatment plan as needed.
Correct Answer is B
Explanation
The correct answer is B.
The client needs assistance with two ADLs.This is because the Katz Index of Independence in Activities of Daily Living (ADLs) is a tool that measures the client’s ability to perform six basic ADLs independently: bathing, dressing, toileting, transferring, continence, and feeding.The score ranges from 0 to 6, with 6 indicating complete independence, 4 indicating moderate impairment, and 2 or less indicating severe dependence.The score is based on the number of ADLs that the client can perform without supervision, direction, personal assistance, or total care.
Therefore, a score of 4 out of 6 means that the client needs assistance with two ADLs.
Choice A is wrong because it implies that the client is independent in all ADLs, which would require a score of 6 out of 6.
Choice C is wrong because it implies that the client is dependent on others for all ADLs, which would require a score of 0 out of 6.
Choice D is wrong because it implies that the client has difficulty with four ADLs, which would require a score of 2 out of 6.
The normal range for the Katz Index of Independence in Activities of Daily Living (ADLs) depends on the setting and population of the client.For example, one study found that the average score for residents in skilled nursing facilities was 3.1 out of 6.Another study found that the hierarchy of difficulty of the six ADLs from least to greatest was: eating, maintaining continence, transferring, toileting, dressing, and bathing.
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