A nurse is assessing a client for orthostatic hypotension. Which actions should the nurse take during the assessment? (Select all that apply)

Choice A reason: When a peripheral pulse is non-palpable due to edema, obesity, or low cardiac output, the nurse should utilize a Doppler ultrasound device. This non-invasive tool amplifies the sound of arterial blood flow, allowing the clinician to verify perfusion that is present but too faint to be detected by manual palpation.

Choice B reason: Elevating the extremity is generally contraindicated when arterial insufficiency is suspected, as gravity can further impede arterial blood flow to the distal tissues. Rechecking in 15 minutes without utilizing alternative assessment tools delays the identification of potential vascular compromise and does not provide new clinical data.

Choice C reason: Documenting the absence of a pulse without further investigation is a failure in the nursing process. The nurse must exhaust all assessment methods, including the use of technology, to determine if the lack of a palpable pulse represents a clinical emergency or simply a technical difficulty in palpation.

Choice D reason: Notifying the provider is premature until the nurse has attempted to locate the pulse using a Doppler. If the Doppler detects a strong signal, the urgency of the situation changes. The provider requires comprehensive assessment data, including Doppler results, to make informed decisions regarding vascular interventions or further diagnostics.

Choice A reason: Teaching a patient with a pre-existing condition how to manage their disease is an example of tertiary prevention. Tertiary prevention aims to minimize the impact of an established permanent or irreversible disease by helping the patient manage symptoms and prevent further disability or complications.

Choice B reason: Rehabilitation after a surgical procedure or injury falls under tertiary prevention. The goal is to restore the patient to their highest possible level of functioning and prevent long-term complications or permanent loss of mobility after the initial acute health event has already occurred.

Choice C reason: Screening for hypertension is an example of secondary prevention. Secondary prevention focuses on early detection of asymptomatic disease through screening and prompt intervention to prevent the progression of the condition. It occurs after the disease process has begun but before symptoms appear.

Choice D reason: Primary prevention involves measures taken to prevent the onset of illness or injury before it occurs. Immunizations, like the flu vaccine, are classic examples of primary prevention because they protect susceptible individuals from contracting an infectious disease, thereby maintaining health and preventing the initial occurrence.