A nurse is educating a client who is 60 years old about strategies to prevent orthostatic hypotension. Which of the following instructions should the nurse include?

(Select all that apply.).

The correct answer is C.

Check for bladder distention or fecal impaction.

Autonomic dysreflexia is a disorder of autonomic nervous system dysregulation that occurs in patients with a spinal cord injury above T6.

It is caused by an exaggerated reflex response of the sympathetic nervous system due to an irritating stimulus below the spinal cord injury.It leads to severe hypertension and is a medical emergency.

Bladder or bowel distension are the most common triggers of autonomic dysreflexia.

Therefore, the priority nursing intervention is to check for bladder distention or fecal impaction and relieve them as soon as possible.

This can help to eliminate the stimulus and lower the blood pressure.

Choice A is wrong because administering antihypertensive medication as prescribed may not be effective or appropriate for autonomic dysreflexia.

The hypertension is caused by a reflex mechanism and not by a primary cardiovascular disorder.Moreover, antihypertensive drugs may cause hypotension once the stimulus is removed.

Choice B is wrong because elevating the head of bed to 90 degrees may not be enough to lower the blood pressure.It may also increase the risk of orthostatic hypotension once the stimulus is removed.However, sitting the patient upright and loosening any tight clothing are recommended as initial steps to reduce the blood pressure.

Choice D is wrong because applying a cooling blanket to lower body temperature is not indicated for autonomic dysreflexia.There is no evidence that body temperature is elevated or contributes to the hypertension in this condition.A cooling blanket may also cause vasoconstriction and worsen the hypertension.

Normal ranges for blood pressure vary depending on age, sex, and other factors.

However, a general guideline is that systolic blood pressure should be less than 120 mm Hg and diastolic blood pressure should be less than 80 mm Hg for most adults.

Normal ranges for heart rate also vary depending on age, activity level, and other factors.

However, a general guideline is that resting heart rate should be between 60 and 100 beats per minute for most adults.

References:.

The correct answer is C.

Ego integrity vs despair.

According to Erikson’s psychosocial theory, older adults face the challenge of looking back on their lives and evaluating their accomplishments and failures.

If they feel satisfied with their life course, they achieve a sense of ego integrity, which is a feeling of wholeness and coherence.

If they feel regretful or dissatisfied, they experience despair, which is a sense of hopelessness and bitterness.

Choice A is wrong because trust vs mistrust is the first stage of Erikson’s theory, which occurs in infancy.

It involves developing a basic sense of trust in oneself and others based on the quality of caregiving.

Choice B is wrong because generativity vs stagnation is the seventh stage of Erikson’s theory, which occurs in middle adulthood.

It involves contributing to society and the next generation through work, parenting, or other activities.

Choice D is wrong because identity vs role confusion is the fifth stage of Erikson’s theory, which occurs in adolescence.

It involves developing a stable and coherent sense of self and one’s role in society.

Normal ranges for Erikson’s stages are:.

• Trust vs mistrust: birth to 18 months.

• Autonomy vs shame and doubt: 18 months to 3 years.

• Initiative vs guilt: 3 to 6 years.

• Industry vs inferiority: 6 to 12 years.

• Identity vs role confusion: 12 to 18 years.

• Intimacy vs isolation: 18 to 40 years.

• Generativity vs stagnation: 40 to 65 years.

• Ego integrity vs despair: 65 years and older.