A nurse is caring for a patient who reports fatigue and had a syncopal episode at home.
The nurse has completed an assessment on the client after the syncopal episode. Complete the following sentence by using the list of options.
The nurse should first address the patient’s
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Answer: The nurse should first address the patient’s oxygen saturation followed by the patient’s hypotension.
Rationale:
1st Priority: Oxygen Saturation → The client’s oxygen saturation has dropped to 88% on room air, which is below the expected range (typically ≥95% in healthy individuals). Hypoxia must be addressed immediately to prevent further complications. The nurse should apply supplemental oxygen and reassess respiratory status.
2nd Priority: Hypotension → The client’s blood pressure has dropped to 94/59 mmHg, which is significantly lower than the earlier reading of 102/76 mmHg. This may contribute to dizziness and syncope. The nurse should monitor for signs of hemodynamic instability, assess for ongoing blood loss (related to heavy menstrual bleeding), and anticipate interventions such as IV fluids or further evaluation for anemia-related hypotension.
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Related Questions
Correct Answer is C
Explanation
A. The patient states having nasal congestion. – Incorrect. Nasal congestion is a symptom of autonomic dysreflexia, not a trigger.
B. The patient’s blood pressure becomes elevated. – Incorrect. Hypertension is a symptom of autonomic dysreflexia, not the cause.
C. The patient’s bladder becomes distended. – Correct Answer. Bladder distention is the most common trigger of autonomic dysreflexia, a life-threatening condition causing sudden hypertension, bradycardia, and severe headache. Immediate intervention is needed, such as catheterizing the bladder.
D. The patient states having a severe headache. – Incorrect. A severe headache is a symptom of autonomic dysreflexia, not a cause.
Correct Answer is A
Explanation
A. Alert and oriented, blood and urine without ketones, no orthostatic blood pressure changes – These findings indicate improved hydration, resolution of hyperosmolarity, and recovery of neurological function, key markers of HHS improvement.
B. Alert and oriented, balanced intake and output, moist mucous membranes – While improved hydration is good, ketone clearance and hemodynamic stability are more important indicators.
C. Respirations easy and unlabored, eats 50-75% of meals, vital signs stable – Respiratory status is not the primary concern in HHS.
D. Equal intake and output, denies pain or shortness of breath – These signs do not specifically indicate resolution of HHS.
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