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 A

Explanation

A. Last dose and type of rescue inhaler used by the child: Knowing the timing and type of rescue medication is critical in an acute asthma exacerbation to determine if additional doses or alternative therapies are needed immediately.

B. Frequency that the child uses a rescue inhaler during the week: While important for long-term asthma management, it is less critical during an acute, life-threatening episode where immediate intervention is required.

C. Type of allergen exposure or trigger for the current episode: Identifying triggers can help prevent future episodes but does not influence immediate treatment for the child’s current severe respiratory distress.

D. Type of inhaler the child typically uses on a regular basis: Knowing routine inhalers is relevant for chronic management but does not provide immediate guidance for emergency treatment of acute airway compromise.

A. 0800: Heart rate 130 beats/minute, blood pressure 190/90 mm Hg; 1200: heart rate 136 beats/minute, blood pressure 200/100 mm Hg, Kussmaul respirations. B. 0800: Heart rate 55 beats/minute, blood pressure 160/70 mm Hg; 1200: heart rate 50 beats/minute, blood pressure 194/70 mm Hg, irregular respirations. C. 0800: Heart rate 110 beats/minute, blood pressure 130/70 mm Hg; 1200: heart rate 100 beats/minute, blood pressure 110/70 mm Hg, shallow respirations. D. 0800: Heart rate 70 beats/minute, blood pressure 120/60 mm Hg; 1200: heart rate 100 beats/minute, blood pressure 90/60 mm Hg, rapid respirations.

Correct Answer is B

Explanation

A. Heart rate 130–136 beats/minute, blood pressure 190–200/90–100 mm Hg, Kussmaul respirations: Although hypertensive and tachycardic, Kussmaul respirations are typically associated with metabolic acidosis rather than ICP. These findings are concerning but not classic for increased ICP.

B. Heart rate 55–50 beats/minute, blood pressure 160/70–194/70 mm Hg, irregular respirations: This pattern reflects Cushing’s triad—bradycardia, hypertension with widening pulse pressure, and irregular respirations—which is a hallmark sign of increased ICP and requires immediate reporting.

C. Heart rate 110–100 beats/minute, blood pressure 130/70–110/70 mm Hg, shallow respirations: Vital signs are not indicative of ICP; shallow respirations may be due to other causes, and the blood pressure trend is decreasing rather than showing hypertension with widening pulse pressure.

D. Heart rate 70–100 beats/minute, blood pressure 120/60–90/60 mm Hg, rapid respirations: These findings suggest hypotension and tachypnea, which are more indicative of hypovolemia or other systemic issues rather than increased ICP.

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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

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