A client taking a blood pressure medication reports feeling dizzy when standing up from a lying position. How should the nurse respond?
"You should sit for a bit before standing up fully."
"You should stand quickly to avoid getting dizzy."
"You should not get out of bed if you are dizzy."
"You should restrict your daily amount of fluid."
The Correct Answer is A
A. "You should sit for a bit before standing up fully.": Feeling dizzy when standing is indicative of orthostatic hypotension, a common side effect of antihypertensive medications. Gradually changing positions by sitting up and pausing before standing helps the body adjust blood pressure and prevents falls. This intervention promotes safety and self-management.
B. "You should stand quickly to avoid getting dizzy.": Rapidly standing exacerbates orthostatic hypotension and increases the risk of falls, injury, and syncope. Quick movements are contraindicated in clients experiencing dizziness related to blood pressure changes.
C. "You should not get out of bed if you are dizzy.": Avoiding mobility altogether can lead to deconditioning and does not address safe strategies for daily activities. The goal is to teach proper techniques to safely transition positions rather than restricting movement entirely.
D. "You should restrict your daily amount of fluid.": Fluid restriction is not appropriate for managing medication-induced dizziness unless medically indicated for other conditions such as heart failure. Limiting fluid intake could worsen hypotension or cause dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Obtain the client's apical heart rate: A radial pulse of 52 beats/minute is below the normal adult range (60–100 bpm), indicating bradycardia. Assessing the apical heart rate provides a more accurate measure of cardiac output and identifies potential discrepancies between central and peripheral pulses. This step is the immediate priority before further interventions.
B. Assess for a pulse deficit: Pulse deficit measurement compares apical and radial pulses to identify ineffective contractions, often in atrial fibrillation. This assessment is secondary and requires the apical pulse first.
C. Notify the healthcare provider: While notification may be necessary depending on findings, the nurse must first verify the heart rate and assess the client’s condition before contacting the provider. Immediate confirmation guides appropriate communication.
D. Review previous vital sign trends: Reviewing trends is useful to determine if bradycardia is new or chronic, but it does not replace the immediate need to accurately assess the current cardiac status. Immediate verification takes priority.
Correct Answer is D
Explanation
A. Contact: Contact precautions are used for infections transmitted by direct or indirect contact with the client or their environment, such as MRSA or C. difficile. Measles is not primarily spread through direct contact, so contact precautions alone are insufficient.
B. Standard: Standard precautions apply to all clients to prevent transmission of bloodborne and body fluid pathogens. While essential, standard precautions alone do not prevent airborne spread of highly contagious respiratory viruses like measles.
C. Droplet: Droplet precautions are used for pathogens transmitted via large respiratory droplets, such as influenza or pertussis. Measles virus is smaller than droplet size and can remain suspended in the air, so droplet precautions alone do not provide adequate protection.
D. Airborne: Measles is highly contagious via airborne transmission. Airborne precautions, including placement in a negative-pressure room and use of an N95 respirator by healthcare personnel, prevent inhalation of aerosolized virus particles. This is the required precaution for measles.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.