A nurse is caring for an 84-year-old male client in the medical unit.
The client was admitted from a provider’s office with complaints of fatigue, dizziness, and shortness of breath. The nurse reviews the client’s medical records to prepare the client’s plan of care.
The client demonstrates mild orthostatic hypotension, with a drop in blood pressure upon standing.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
The Correct Answer is []
Based on the provided information, the client is most likely experiencing Anemia. Here’s how the diagram should be completed:
Condition
- Anemia
Actions to Take
- Administer prescribed medications
- Monitor vital signs regularly
Parameters to Monitor
- Hemoglobin levels
- Blood pressure
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
The ropes being in the center of the wheel grooves is correct and ensures proper traction.
Choice B rationale
The ropes being securely attached to the pins is correct and necessary for effective traction.
Choice C rationale
The weights being equal on each side is correct and ensures balanced traction.
Choice D rationale
The weights resting against the foot of the bed is incorrect and can interfere with the effectiveness of the traction. .
Correct Answer is D
Explanation
Choice D rationale
Positioning the client on the abdomen for 20 to 30 minutes twice a day helps prevent hip flexion contractures. This position stretches the hip flexor muscles, reducing the risk of contractures and promoting better range of motion.
Choice A rationale
Maintaining the client in a supine position does not effectively prevent hip flexion contractures. It is important to vary the client’s position to avoid stiffness and promote mobility.
Choice B rationale
Maintaining a high-Fowler’s position when the client is in bed can increase the risk of hip flexion contractures. This position keeps the hip flexed, which can lead to contractures over time.
Choice C rationale
Elevating the stump on a pillow can help reduce swelling but does not address the prevention of hip flexion contractures. The focus should be on positioning that stretches the hip flexors.
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