An elderly patient who lives in a skilled nursing facility and who likes to walk is taking a medication that lowers blood pressure by dilating blood vessels. The best nursing action for this patient is to:
Suggest total bed rest.
Assist the patient when ambulating in the hall.
Monitor intake and output.
Instruct the resident to rise slowly when getting out of bed or a chair.
The Correct Answer is D
Choice A reason: Bed rest increases clot risk and deconditioning; vasodilators lower pressure, but mobility is beneficial unless contraindicated, making this overly restrictive.
Choice B reason: Assisting ambulation helps, but it’s less proactive; it doesn’t address orthostatic hypotension risks at initiation of movement, where falls are most likely.
Choice C reason: Monitoring intake/output tracks fluid status, not directly addressing vasodilation’s hypotensive effects during position changes, missing the primary safety concern.
Choice D reason: Rising slowly counters orthostatic hypotension from vasodilation; it allows autoregulation to stabilize pressure, reducing fall risk in an active elderly patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Lisinopril is Zestril’s generic name; an ACE inhibitor, it’s widely used for hypertension, matching the context of a common medication order.
Choice B reason: Acetaminophen, a pain reliever, isn’t Zestril’s generic; it lacks antihypertensive action, making it irrelevant to the implied medication class.
Choice C reason: Morphine, an opioid, treats pain, not hypertension; it doesn’t align with Zestril’s purpose or class, ruling it out as the generic name.
Choice D reason: Fentanyl, another opioid, addresses pain, not blood pressure; it’s unrelated to Zestril’s therapeutic role, excluding it from consideration.
Correct Answer is D
Explanation
Choice A reason: Assuming patient preference lacks evidence; without asking, this dismisses autonomy, potentially misrepresenting the patient’s comfort with spiritual interventions.
Choice B reason: Endorsing without consent is inappropriate; the patient’s lack of affiliation suggests possible rejection, and this risks imposing unwanted religious activity.
Choice C reason: Doctor’s order isn’t required; prayer is a chaplain’s role, not medical, but patient consent is still needed, making this an unnecessary step.
Choice D reason: Permission respects autonomy; without religious affiliation, the patient may decline, and consent ensures ethical care aligned with individual beliefs.
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