A client presents to the medical surgical unit.

Which of the following findings requires further action by the nurse? Select all that apply.

A) *Restrict your daily fluid intake: Restricting fluid intake is not recommended for a client experiencing lightheadedness upon standing, especially when taking an ACE inhibitor. In fact, maintaining adequate hydration is important to help prevent hypotension, which could be exacerbated by fluid restriction. The lightheadedness may be due to orthostatic hypotension, which is a common side effect of ACE inhibitors.

B) *Take a daily potassium supplement: ACE inhibitors can increase potassium levels in the blood, potentially leading to hyperkalemia. For most clients, taking a potassium supplement is not necessary unless specified by the healthcare provider. In fact, many clients taking ACE inhibitors need to avoid excessive potassium intake, unless directed otherwise, to prevent dangerous potassium levels.

C) *Discontinue this medication if this occurs again: The nurse should not advise the client to discontinue the medication without consulting the healthcare provider. Lightheadedness upon standing is a common side effect of ACE inhibitors due to their blood pressure-lowering effects, and the healthcare provider should be notified if this becomes problematic. The decision to change or discontinue the medication should be made by the provider.

D) "Sit back down for a few minutes when this occurs": This is the most appropriate advice. Lightheadedness upon standing can be a sign of orthostatic hypotension, which is a known side effect of ACE inhibitors. The client should be instructed to sit down and rest when they experience these symptoms. If necessary, they should stand up slowly to allow their body to adjust to changes in position, which can help alleviate the lightheadedness.

A) Mongolian spots: Mongolian spots are common in newborns of Asian, Hispanic, and African descent and are not specifically associated with fetal alcohol syndrome (FAS). These spots are bluish-gray or purple and typically fade over time, but they are not a manifestation of FAS.

B) Microcephaly: Microcephaly, which is an abnormally small head, is a common feature of fetal alcohol syndrome. This condition results from the effects of alcohol on the developing brain during pregnancy, leading to a smaller-than-normal head size.

C) Single palmar crease: A single palmar crease is a common finding in Down syndrome and can occur in other conditions as well, but it is not a hallmark feature of fetal alcohol syndrome. While it may occasionally be seen in infants with FAS, it is not one of the most common or defining characteristics.

D) Thin upper lip: A thin upper lip is one of the hallmark facial features of fetal alcohol syndrome. It is part of the characteristic "facial dysmorphology" seen in FAS, along with other features such as a smooth philtrum

E) Small eyes: Small eyes, or microphthalmia, are also a characteristic feature of fetal alcohol syndrome. This abnormal eye size, along with other facial abnormalities, is often seen in infants affected by FAS.