An older client reports experiencing frequent dizzy spells. To assess for orthostatic hypotension, which action should the nurse take first?

Assist client to a supine position.

Instruct the client to stand upright.

Place the client in a semi-Fowler's position.

Help the client sit on the side of the bed.

Answer and Explanation

The Correct Answer is A

A. Assist client to a supine position: The initial step in assessing orthostatic hypotension is to have the client lie supine for several minutes. This allows baseline blood pressure and heart rate to be measured in a stable, resting position before changing posture.

B. Instruct the client to stand upright: Standing too soon without establishing baseline measurements may place the client at risk for falls or injury due to dizziness or sudden blood pressure changes.

C. Place the client in a semi-Fowler's position: A semi-Fowler’s position is partially upright, which does not provide an accurate baseline for assessing orthostatic changes compared to the supine position.

D. Help the client sit on the side of the bed: Sitting at the bedside is part of the assessment sequence, but it should occur after obtaining supine baseline readings to safely monitor changes in blood pressure and heart rate.

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Correct Answer is C

Explanation

A. Glucose and calcium levels: While hyperglycemia can occur secondary to stress, glucose and calcium are not the primary indicators of severity in a thyrotoxic crisis.

B. Blood and urine cultures: Cultures are important if infection is suspected as a trigger, but they do not reflect the systemic impact of a thyrotoxic crisis itself.

C. Renal and liver function tests: Thyrotoxic crisis can lead to multi-organ stress, including hepatic dysfunction and impaired renal perfusion. Monitoring liver enzymes and renal function helps detect complications early and guide interventions.

D. Electrolytes and hemoglobin: Electrolytes may fluctuate and anemia may exist, but they are not the most critical values to monitor during the acute phase of a thyrotoxic crisis compared with organ function indicators.

A. Irrigate conjunctiva with ophthalmic saline prior to instilling antibiotic ointment. B. Limit exposure to sunlight during the first 2 weeks when the cornea is healing. C. Avoid straining at stool, bending, or lifting heavy objects. D. Do not read without direct lighting for 6 weeks.

Correct Answer is C

Explanation

A. Irrigate conjunctiva with ophthalmic saline prior to instilling antibiotic ointment: Routine irrigation is not typically necessary unless instructed for debris removal. Over-manipulation may increase the risk of infection or injury to the healing eye.

B. Limit exposure to sunlight during the first 2 weeks when the cornea is healing: While sunglasses can protect the eyes from UV light, strict limitation of sunlight is not usually required for 2 weeks. Standard protective measures and avoiding direct glare are sufficient.

C. Avoid straining at stool, bending, or lifting heavy objects: These activities increase intraocular pressure, which can compromise the surgical site and healing process after cataract extraction. Avoiding them is critical to prevent complications such as wound dehiscence or hemorrhage.

D. Do not read without direct lighting for 6 weeks: Reading is generally safe after cataract surgery as long as the client uses appropriate lighting. There is no standard requirement to avoid reading for 6 weeks.

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An older client reports experiencing frequent dizzy spells. To assess for orthostatic hypotension, which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which laboratory values are critical for the nurse to monitor for a client who is experiencing a thyrotoxic crisis?

Correct Answer is C

Explanation

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Correct Answer is C

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