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.
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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Related Questions
Correct Answer is C
Explanation
A. Encourage the wife to voice her feelings about having a husband with Parkinson's disease: While it is important to provide emotional support and encourage expression of feelings, this does not address her specific question about alternative or complementary cures.
B. Tell the wife that her husband's neurologist would know more about alternative treatments to cure Parkinsonism: Referring to the neurologist may seem appropriate, but it avoids answering the wife’s concern directly.
C. Explain that there are no known conventional, alternative, or complimentary therapies that cure Parkinson's disease: Parkinson’s is a progressive neurodegenerative disorder, and while medications and some therapies can manage symptoms, no cure currently exists. This response provides clear, evidence-based information and directly answers the wife’s question.
D. Compile a list of alternative medications that are effective in curing Parkinson's disease: No alternative or complementary medications have been proven to cure Parkinson’s disease. Providing such a list would give false hope and misinformation.
Correct Answer is D
Explanation
A. Administer prescribed PRN sleep medications: While adequate rest is important for postpartum recovery, it does not address the immediate risk to the client’s healing perineal tissue and comfort related to the fourth-degree laceration.
B. Encourage use of prescribed analgesic perineal sprays: Pain management is important for comfort and mobility, but it does not prevent complications such as wound disruption or trauma during defecation, which could impair healing.
C. Encourage breastfeeding to promote uterine involution: Breastfeeding supports uterine contraction and reduces postpartum bleeding, but it does not directly impact the care and protection of a severe perineal laceration.
D. Administer prescribed stool softener: Preventing straining during bowel movements is critical in promoting healing of a fourth-degree perineal laceration. Stool softeners reduce the risk of trauma to the repaired tissue, prevent pain, and minimize potential complications such as wound dehiscence.
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