A nurse plans to assess a client for orthostatic hypotension after the client reports dizziness when standing. Which action should the nurse take first?
Assist the client to a standing position and immediately measure blood pressure.
Encourage the client to ambulate in the hallway to reproduce symptoms.
Measure the client's blood pressure and heart rate while the client is lying supine.
Ask the client to sit at the side of the bed and report any dizziness.
The Correct Answer is C
Rationale:
A. Assisting the client to a standing position and immediately measuring blood pressure is part of the orthostatic vital signs assessment, but it is not the first step. Jumping straight to standing measurements without a baseline can lead to inaccurate interpretations, because orthostatic hypotension is defined as a significant drop in blood pressure upon changing position from supine to standing. Starting with standing measurements alone would not allow the nurse to determine if a drop has actually occurred.
B. Encouraging the client to ambulate in the hallway to reproduce symptoms is inappropriate as an initial action. Since the client has reported dizziness upon standing, having them walk unsupervised could increase the risk of falls and injury. Patient safety is a priority, so controlled assessment of vital signs must occur before ambulation.
C. Measuring the client’s blood pressure and heart rate while lying supine is the correct first step. This provides a baseline reading of vital signs in a resting position, which is essential for accurate comparison. Once the baseline is obtained, the nurse can measure vital signs while the client is sitting and then standing. Orthostatic hypotension is diagnosed when there is a drop of 20 mmHg or more in systolic blood pressure, a drop of 10 mmHg or more in diastolic blood pressure, or a heart rate increase of 20 beats per minute or more upon standing. Obtaining a supine baseline ensures these changes are accurately detected.
D. Asking the client to sit at the side of the bed and report any dizziness is part of the assessment sequence, but it occurs after obtaining baseline supine measurements. Sitting at the side of the bed is a transitional position before standing, and allows the nurse to monitor for symptoms safely.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. The normal adult respiratory rate ranges from 12 to 20 breaths per minute. A rate of 20 is at the upper end of normal and generally does not indicate respiratory compromise. While the nurse should continue routine monitoring, no immediate intervention is necessary in this context.
B. This is below the normal range and constitutes bradypnea, which is particularly concerning in a client receiving opioids. Opioid medications, such as morphine, hydromorphone, or fentanyl, can depress the central nervous system, leading to slowed or inadequate respirations. A respiratory rate of 8 breaths per minute indicates significant respiratory depression, which can result in hypoxia (low oxygen levels), hypercapnia (excess carbon dioxide), altered mental status, and potentially respiratory arrest if not addressed immediately. The nurse must take urgent action, which includes stopping or reducing the opioid if appropriate, stimulating the client to breathe, administering supplemental oxygen, monitoring oxygen saturation and vital signs, and notifying the prescribing provider. Early recognition and intervention are critical to prevent life-threatening complications.
C. This falls within the normal adult range and does not indicate respiratory compromise. The nurse should continue standard monitoring but no immediate action is required.
D. This is also within the normal adult range and reflects adequate ventilation. It does not necessitate immediate intervention.
Correct Answer is A
Explanation
Rationale:
A. Macular degeneration primarily affects the macula, the central portion of the retina responsible for sharp, detailed vision. A decrease in central vision is the hallmark symptom of this condition, often making tasks such as reading, recognizing faces, and driving difficult. Peripheral vision is usually preserved in early stages, which differentiates it from other visual impairments.
B. Cataracts cause clouding of the lens, leading to blurred vision, glare, and difficulty seeing in low light. Cataracts generally affect overall vision rather than selectively impairing central vision. Therefore, a report of decreased central vision alone is not specific to cataracts.
C. Diabetic retinopathy involves damage to retinal blood vessels, leading to spots, floaters, blurred vision, or vision loss. While it can affect central vision in advanced stages, the early manifestation is usually patchy or scattered visual changes, not isolated central vision loss.
D. Glaucoma typically causes peripheral vision loss first, often progressing to tunnel vision if untreated. Central vision is preserved until the late stages, making glaucoma less likely to be the cause of a recent decrease in central vision.
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