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 isA, D, and E.

Here is why:.

A. Elevated white blood cell count.

This is a sign of infection and inflammation in the body, which can be caused by a UTI.An elevated white blood cell count can also indicate a complication of UTI such as pyelonephritis (kidney infection) or sepsis (blood infection).

D. Altered mental status.

This is a common symptom of UTI in older adults, especially those with dementia or other cognitive impairments.UTIs can cause confusion, agitation, delirium, or behavioral changes in the elderly due to the effects of infection and inflammation on the brain.

E. Positive urine culture.

This is the definitive test to diagnose a UTI, as it identifies the type and number of bacteria present in the urine.A positive urine culture confirms the presence of a UTI and guides the appropriate antimicrobial treatment.

The other choices are wrong because:.

•.

B. Decreased serum creatinine level.

This is not a sign of UTI or its complications.

Serum creatinine is a measure of kidney function, and it usually increases when the kidneys are damaged or impaired.A decreased serum creatinine level may indicate other conditions such as liver disease, muscle wasting, or malnutrition.

•.

C. Increased urine specific gravity.

This is not a sign of UTI or its complications.

Urine specific gravity is a measure of urine concentration, and it usually increases when the body is dehydrated or has high levels of solutes in the urine.An increased urine specific gravity may indicate other conditions such as diabetes mellitus, heart failure, or dehydration.

Normal ranges for some of these tests are:.

• White blood cell count: 4,000 to 11,000 cells per microliter (mcL) of blood.

• Serum creatinine: 0.6 to 1.2 milligrams per deciliter (mg/dL) for men and 0.5 to 1.1 mg/dL for women.

• Urine specific gravity: 1.005 to 1.030.