The nurse is assisting an older adult patient out of bed when suddenly the patient begins to fall. What is the likely cause of the fall?
Fever
A decrease in venous return
Orthostatic hypotension
Dehydration
The Correct Answer is C
A. Fever: Fever can cause weakness or dizziness, but it is not a sudden cause of falling when getting up.
B. A decrease in venous return can contribute to orthostatic hypotension but is not a direct cause on its own.
C. Orthostatic hypotension is a common cause of sudden falls in older adults when they change positions, leading to dizziness or fainting.
D. Dehydration can lead to orthostatic hypotension but is not as direct a cause of sudden falls when getting up as orthostatic hypotension itself.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Monitor for signs of seizure activity: Seizure activity is not directly related to the condition described.
B. Increase the IV rate and monitor for burn shock: Increasing the IV rate could exacerbate fluid overload; burn shock is more of a concern in the initial hours post-burn.
C. Raise the foot of the bed and apply blankets. This is not relevant to addressing the issue of large urine output.
D. Assess for signs of fluid overload: After the initial fluid resuscitation phase, large urine output may indicate that fluid is being mobilized from the tissues back into the vascular system, potentially leading to fluid overload.
Correct Answer is B
Explanation
A. Take her blood pressure twice a day to check for hypertension. Lithium does not typically cause hypertension. Monitoring blood pressure is not a primary concern for patients on lithium.
B. Have her drug blood level checked every month. Regular monitoring of lithium blood levels is crucial to ensure therapeutic levels and avoid toxicity. Lithium has a narrow therapeutic window, and frequent monitoring helps in adjusting the dose to maintain safe and effective levels.
C. Avoid aged cheese and red wine. This advice is relevant for patients taking MAOIs, not lithium. There is no need for patients on lithium to avoid these foods specifically.
D. Examine her skin closely for eruptions. While skin eruptions can be a side effect of some medications, it is not a primary concern for patients on lithium. The focus should be on monitoring for signs of lithium toxicity and other common side effects like tremors, thyroid dysfunction, and renal impairment.
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