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 B

Explanation

A. Initiate passive range of motion exercises: While important for preventing contractures and maintaining mobility in the affected limbs, this intervention does not address the immediate risk associated with dysphagia, such as aspiration.

B. Facilitate a consultation for speech therapy: Speech therapy can assess and provide interventions for both communication deficits and swallowing difficulties. Addressing dysphagia is critical to prevent aspiration, choking, and malnutrition, making this the highest-priority intervention.

C. Use pictures and gestures to communicate: Supporting communication is important for client engagement and safety, but it does not directly address the physiological risks associated with swallowing difficulties.

D. Arrange for daily home care assistance: Planning for post-discharge care is necessary for long-term support, but immediate assessment and intervention for dysphagia take priority to ensure the client’s safety during the current hospitalization.

A. Absent sounds. B. Pain. C. Musical and drumlike. D. Tenderness. E. Auscultate for presence of bilateral breath sounds.

Correct Answer is C

Explanation

A. Absent sounds: Absent bowel sounds are abnormal and may indicate an ileus, obstruction, or decreased intestinal motility, requiring further assessment.

B. Pain: Pain elicited during percussion is not a normal finding and may indicate underlying pathology such as inflammation, infection, or organ enlargement.

C. Musical and drumlike: Tympany, which produces a musical, drumlike sound during percussion, is a normal finding over air-filled structures in the abdomen. It indicates the presence of gas in the stomach and intestines, reflecting normal gastrointestinal function.

D. Tenderness: Tenderness on percussion is abnormal and may suggest inflammation, infection, or other abdominal pathology requiring further evaluation.

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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

An older adult client is referred to a rehabilitation facility following a cerebrovascular accident (CVA).The client is aphasic with left sided paresis and is having difficulty swallowing. Which intervention is most important for the nurse to include in the client's plan of care?

Correct Answer is B

Explanation

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Correct Answer is C

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