An older adult client’s assessment reveals the following data: Lying BP 144/82 mm Hg, sitting BP 121/69 mm Hg, standing BP 98/56 mm Hg. What nursing diagnosis should be identified in the client’s plan of care?
Risk for ineffective breathing pattern related to hypotension
Risk for falls related to orthostatic hypotension
Risk for ineffective role performance related to hypotension
Risk for imbalanced fluid balance related to hemodynamic variability
The Correct Answer is B
correct answer is Choice B.
Choice B rationale:
Orthostatic hypotension is a significant drop in blood pressure that occurs when a person stands up from a lying or sitting position. It's characterized by a decrease in systolic blood pressure of at least 20 mmHg or a decrease in diastolic blood pressure of at least 10 mmHg within 3 minutes of standing.
The client's assessment data clearly demonstrates orthostatic hypotension, with a systolic blood pressure drop of 23 mmHg and a diastolic drop of 13 mmHg upon standing.
Orthostatic hypotension is a major risk factor for falls, especially in older adults. This is because the sudden decrease in blood pressure can lead to lightheadedness, dizziness, blurred vision, weakness, and even fainting.
Falls in older adults can result in serious injuries, such as fractures, head trauma, and even death. Therefore, it's crucial to identify and address orthostatic hypotension to prevent falls and their associated complications.
Rationales for other choices:
Choice A: Ineffective breathing pattern is not directly related to orthostatic hypotension. While hypotension can cause shortness of breath in some cases, it's not the primary concern in this scenario.
Choice C: Ineffective role performance can be a consequence of frequent falls, but it's not the most immediate or pressing nursing diagnosis in this case.
Choice D: Risk for imbalanced fluid balance is a potential concern in some cases of orthostatic hypotension, but it's not the most likely diagnosis based on the client's assessment data.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Digoxin is a medication that slows the heart rate. It would be contraindicated in this patient because they are already bradycardic.
Administering digoxin could further slow the heart rate and worsen the patient's symptoms.
Additionally, digoxin can have a negative inotropic effect, which could further compromise the patient's hemodynamic status. Choice B rationale:
While it is important to continue to monitor the patient, this is not an intervention that will address the patient's bradycardia and hypotension.
The patient is already symptomatic, and their heart rate and blood pressure are likely to continue to decline without intervention. Choice C rationale:
Defibrillation is used to treat life-threatening arrhythmias such as ventricular fibrillation and pulseless ventricular tachycardia.
It is not indicated for sinus bradycardia.
Choice D rationale:
Transcutaneous pacing is a non-invasive method of pacing the heart.
It can be used to temporarily increase the heart rate in patients with symptomatic bradycardia.
This is the most appropriate intervention for this patient because it will address the underlying problem of bradycardia and improve the patient's hemodynamic status.
Correct Answer is B
Explanation
Choice A rationale:
Increased afterload refers to the resistance against which the heart must pump to eject blood into the aorta.
While increased afterload can contribute to angina by increasing the heart's workload, it is not the primary cause of the pain.
Increased afterload is more commonly associated with heart failure, hypertension, and aortic stenosis.
Choice C rationale:
The coronary artery system is the network of blood vessels that supply oxygen and nutrients to the heart muscle.
While coronary artery disease (CAD), a narrowing or blockage of these arteries, is the underlying cause of angina, it is not the direct cause of the pain.
The pain of angina is caused by the heart muscle not receiving enough oxygen, which can occur even if the coronary arteries are not completely blocked.
Choice D rationale:
Increased preload refers to the volume of blood that fills the ventricles before they contract.
While increased preload can also contribute to angina by increasing the heart's workload, it is not the primary cause of the pain.
Increased preload is more commonly associated with heart failure, valvular regurgitation, and fluid overload.
Choice B rationale:
Inadequate myocardial oxygenation is the most direct and accurate explanation for the pain of angina.
When the heart muscle does not receive enough oxygen, it experiences ischemia, which is a lack of blood flow and oxygen.
Ischemia triggers the release of chemicals that stimulate pain receptors in the heart, leading to the characteristic chest pain of angina.
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