A nurse is monitoring a client in a telemetry unit.

Exhibits

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 Z parameters the nurse should monitor to assess the client's progress

Rationale for correct choices:

• Orthostatic hypotension: The client’s dizziness when standing, which improves with rest, is characteristic of orthostatic hypotension. This condition can occur due to vasodilation from antihypertensive therapy, such as amlodipine, or age-related cardiovascular changes. Monitoring symptoms and educating the client are essential to prevent falls and injury.
• Instruct the client to avoid sudden position changes: Gradually changing positions allows the cardiovascular system to compensate for shifts in blood pressure. Slow transitions from lying to sitting to standing help reduce dizziness, lightheadedness, and the risk of falls.
• Monitor for orthostatic hypotension: Assessing blood pressure and heart rate in different positions identifies significant drops in systolic or diastolic pressure. Early detection allows timely interventions, such as adjusting medications or providing fluid support, to prevent complications.
• Blood pressure: Continuous monitoring tracks trends and reveals whether the antihypertensive regimen is contributing to symptomatic hypotension. It guides clinical decision-making regarding medication adjustments or additional interventions to maintain hemodynamic stability.
• Heart rate: Monitoring heart rate provides insight into the body’s compensatory response to hypotension. An appropriate increase in heart rate can offset drops in blood pressure, while inadequate compensation may indicate a higher risk for dizziness, syncope, or falls.

Rationale for incorrect choices:

• Pulmonary edema: The client has no shortness of breath, crackles, or edema, which are hallmark signs of pulmonary congestion. This makes pulmonary edema an unlikely cause of the current symptoms, so interventions targeting fluid overload are not indicated.
• Bradycardia: The client’s heart rate is within normal limits (72–78/min) and does not reflect clinically significant bradycardia. Therefore, interventions specific to low heart rate are not needed in this scenario.
• Hyperglycemia: There is no evidence of elevated blood glucose levels or symptoms such as polyuria, polydipsia, or fatigue. Monitoring for hyperglycemia is not relevant to the client’s dizziness associated with orthostatic changes.
• Apply compresses to forehead: While comforting, this does not address the underlying cause of orthostatic hypotension. Symptom relief without addressing postural blood pressure changes does not prevent falls or injury.
• Administer intravenous fluids: IV fluids are only indicated if hypovolemia is present. The client shows stable hydration, so administering fluids would be unnecessary and could potentially cause fluid overload.
• Increased potassium intake: There is no evidence of hypokalemia contributing to the dizziness or hypotension. Potassium supplementation is not indicated in this situation.
• Electrolyte levels: Monitoring electrolytes is not essential here because the client’s symptoms are primarily postural and related to antihypertensive therapy rather than an electrolyte imbalance.
• Respiratory rate: The client’s respiratory rate is normal and not related to orthostatic hypotension. Therefore, focusing on this parameter does not provide actionable information for the current condition.
• Blood glucose levels: There are no indications of diabetes or hyperglycemia contributing to the client’s symptoms, so monitoring blood glucose is unnecessary in this scenario.