An older adult client’s assessment reveals the following data: Lying BP 144/82 mm Hg, sitting BP 121/69 mm Hg, standing BP 98/56 mm Hg. What nursing diagnosis should be identified in the client’s plan of care?

Risk for ineffective breathing pattern related to hypotension

Risk for falls related to orthostatic hypotension

Risk for ineffective role performance related to hypotension

Risk for imbalanced fluid balance related to hemodynamic variability

Answer and Explanation

The Correct Answer is B

correct answer is Choice B.

Choice B rationale:

Orthostatic hypotension is a significant drop in blood pressure that occurs when a person stands up from a lying or sitting position. It's characterized by a decrease in systolic blood pressure of at least 20 mmHg or a decrease in diastolic blood pressure of at least 10 mmHg within 3 minutes of standing.

The client's assessment data clearly demonstrates orthostatic hypotension, with a systolic blood pressure drop of 23 mmHg and a diastolic drop of 13 mmHg upon standing.

Orthostatic hypotension is a major risk factor for falls, especially in older adults. This is because the sudden decrease in blood pressure can lead to lightheadedness, dizziness, blurred vision, weakness, and even fainting.

Falls in older adults can result in serious injuries, such as fractures, head trauma, and even death. Therefore, it's crucial to identify and address orthostatic hypotension to prevent falls and their associated complications.

Rationales for other choices:

Choice A: Ineffective breathing pattern is not directly related to orthostatic hypotension. While hypotension can cause shortness of breath in some cases, it's not the primary concern in this scenario.

Choice C: Ineffective role performance can be a consequence of frequent falls, but it's not the most immediate or pressing nursing diagnosis in this case.

Choice D: Risk for imbalanced fluid balance is a potential concern in some cases of orthostatic hypotension, but it's not the most likely diagnosis based on the client's assessment data.

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

Explanation

Choice A rationale:

The ST segment represents the period of time between ventricular depolarization and repolarization. Its elevation or depression can indicate myocardial ischemia or injury, but it's not directly related to normal sinus rhythm determination.

The PR interval, on the other hand, measures the time it takes for the electrical impulse to travel from the atria to the ventricles. While a normal PR interval is essential for normal sinus rhythm, its height relative to the ST segment is not a determining factor.

Choice B rationale:

The number of complexes in a 6-second strip can provide a quick estimate of heart rate, but it's not a definitive criterion for normal sinus rhythm. A normal heart rate in adults typically ranges from 60 to 100 beats per minute, which could correspond to 5-10 complexes in a 6-second strip. However, other factors, such as rhythm regularity and P wave morphology, must also be considered. Choice C rationale:

RR intervals that are relatively consistent are a hallmark of normal sinus rhythm. This indicates that the heart is beating at a regular pace, with equal time intervals between each QRS complex. In contrast, irregular RR intervals suggest dysrhythmia, such as atrial fibrillation or premature ventricular contractions.

Choice D rationale:

One P wave preceding each QRS complex is another essential feature of normal sinus rhythm. The P wave represents atrial depolarization, and its consistent presence before each QRS complex (which represents ventricular depolarization) indicates that the electrical impulse is originating in the sinoatrial (SA) node, the heart's natural pacemaker, and is propagating through the atria and ventricles in a coordinated manner.

A. Bleeding and wound dehiscence. B. Wound dehiscence and evisceration. C. Thrombosis and infection. D. Bleeding and infection.

Correct Answer is D

Explanation

Choice A rationale:

Bleeding is a concern due to the recent surgery and heparin therapy, which can increase bleeding risk. However, wound dehiscence (wound separation) is less likely in a percutaneous insertion compared to open surgery.

Percutaneous insertion involves a smaller incision and less tissue disruption, reducing the chances of wound dehiscence.

While monitoring for bleeding is crucial, wound dehiscence may not be the most immediate concern in this specific scenario.

Choice B rationale:

Wound dehiscence and evisceration (protrusion of internal organs) are serious complications, but they are less likely to occur with percutaneous insertion compared to open surgery.

The smaller incision and minimal tissue disruption in percutaneous insertion lower the risk of these complications.

While vigilance for wound complications is essential, the priority in this case lies with bleeding and infection.

Choice C rationale:

Thrombosis (blood clot formation) is a potential complication of IVC filter placement, but it's not typically associated with the surgical site itself.

Infection is a concern for any surgical procedure, but it's not the most immediate risk in this scenario given the emphasis on bleeding and the patient's recent heparin therapy.

Choice D rationale:

Bleeding:

Heparin therapy, a blood thinner, increases the risk of bleeding.

The surgical site is a potential area for bleeding, as it involves disruption of blood vessels.

Meticulous monitoring for bleeding is essential to ensure prompt intervention if it occurs.

Infection:

Any surgical procedure carries a risk of infection.

The surgical site is a potential entry point for bacteria.

Close observation for signs of infection, such as redness, swelling, warmth, or drainage, is crucial for early detection and treatment.

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An older adult client’s assessment reveals the following data: Lying BP 144/82 mm Hg, sitting BP 121/69 mm Hg, standing BP 98/56 mm Hg. What nursing diagnosis should be identified in the client’s plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What criteria should the nurse use to determine normal sinus rhythm for a client on a cardiac monitor? Select all that apply.

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

Explanation

A nurse is caring for a client who had a percutaneous insertion of an inferior vena cava filter and was on heparin therapy before surgery. The nurse would inspect the surgical site most closely for signs of:

Correct Answer is D

Explanation

Please identify the following rhythm:

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