A nurse enters a emergency department has the following vital signs: blood pressure 111/76 mm Hg, pulse 69 beats/min, temperature 37.1°C (98.8°F), respiration 28/min and SpO2 91% on room air. Which of these findings is outside the expected reference range for an adult? (Select all that apply)

Asymmetrical shoulder height is a clinical indicator of lateral spinal curvature, commonly known as scoliosis, or potential neuromuscular imbalances. When an abnormality is identified during a general survey, the nurse must transition to a focused physical examination to determine the severity, evaluate for compensatory mechanisms, and gather objective data such as the presence of a rib hump during a forward bend test.

A. Conducting a focused musculoskeletal assessment is the priority action. This allows the nurse to gather more specific information, such as performing the Adam’s Forward Bend test to differentiate between structural and functional scoliosis. Identifying whether the asymmetry is associated with spinal rotation, limb length discrepancy, or muscular weakness is essential for clinical decision-making.

B. Attempting to reposition the client to "correct" their posture is an ineffective and potentially misleading intervention. If the asymmetry is caused by a structural skeletal deformity like scoliosis, the client cannot simply adjust their posture to eliminate the finding. This action ignores the underlying physiological cause and fails to assess the extent of the abnormality.

C. While the healthcare provider will eventually need to be notified of the findings, the nurse must first complete a focused assessment to provide a comprehensive and detailed report. Notifying the provider without having assessed the degree of curvature or associated symptoms like pain or respiratory restriction would be an incomplete nursing action.

D. Documenting the finding and continuing with the general assessment without further investigation is inappropriate. Asymmetry in a major skeletal landmark requires immediate diagnostic scrutiny to ensure that progressive conditions are identified early. Skipping the focused assessment misses a critical opportunity to evaluate the client’s functional and structural integrity.

Orthostatic hypotension is defined by a systolic decrease of ≥20 mmHg or a diastolic decrease of ≥10 mmHg upon standing. This condition stems from autonomic failure or hypovolemia, leading to inadequate cerebral perfusion and a high risk for falls or syncopal episodes.

A. Administering a diuretic is contraindicated in orthostatic hypotension because it promotes diuresis and further reduces intravascular volume. Lowering the blood volume would exacerbate the drop in pressure when the client stands. This could lead to severe hypovolemic shock or increased frequency of fainting spells.

B. While increasing sodium intake can help expand extracellular fluid volume in some chronic cases, it is not an immediate nursing intervention for a client experiencing the condition. Excessive sodium can also lead to complications like hypertension or edema. It requires medical oversight rather than being a primary intervention.

C. Caffeinated beverages are generally not recommended as a primary treatment for orthostatic hypotension. While caffeine causes temporary vasoconstriction, its diuretic effect can eventually lead to fluid loss. Reliance on stimulants does not address the underlying baroreceptor reflex dysfunction that typically causes the postural drop.

D. Encouraging the client to change positions slowly allows the autonomic nervous system more time to compensate for the gravitational shift of blood. Gradual movement prevents the sudden pooling of blood in the lower extremities. This nursing action is the most effective way to maintain cerebral perfusion and safety.