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?

Choice A rationale:

Venous thromboembolism (VTE) is a blood clot that forms in a vein, usually in the legs. It can be a serious condition, as the clot can break loose and travel to the lungs, causing a pulmonary embolism (PE).

Crossing the legs at the knees can impede blood flow in the veins of the legs, increasing the risk of VTE. This is because it compresses the veins, slowing the flow of blood and making it more likely for clots to form.

The patient's statement that they will make sure not to cross their legs when resting in bed demonstrates that they understand this important risk factor for VTE and are taking steps to prevent it.

Choice B rationale:

While keeping pillows under the knees can help to improve circulation, it is not a specific measure to prevent VTE. It is more important to avoid crossing the legs and to engage in regular movement and activity to promote blood flow.

Choice C rationale:

Compression stockings can help to reduce the risk of VTE by compressing the veins in the legs and promoting blood flow. However, they should be worn as instructed by a healthcare professional, and not only if the patient experiences pain in their calves. Pain in the calves can be a symptom of VTE, so it is important to seek medical attention if it occurs.

Choice D rationale:

Bed rest is actually a risk factor for VTE, as it can lead to decreased blood flow in the legs. It is important to get up and move around as soon as possible after surgery, even if it is just for short periods of time. This will help to promote blood flow and reduce the risk of VTE.

Choice B rationale:

It is crucial to ensure that no one is touching the client during defibrillation to prevent accidental electrical shock to others. The electrical current delivered by the defibrillator is extremely powerful and can cause serious injury or even death if it passes through another person's body. This includes both healthcare professionals and bystanders.

Here are key points to emphasize this rationale:

Electrical conduction: The human body is a good conductor of electricity. If someone is touching the client during defibrillation, the electrical current from the defibrillator can easily pass through their body, potentially causing harm.

Cardiac rhythm disruption: Any contact with the client during shock delivery can interfere with the defibrillator's ability to accurately assess the client's heart rhythm and deliver the appropriate shock. This could potentially worsen the client's condition.

Muscle contractions: The electrical current from the defibrillator can cause involuntary muscle contractions. If someone is touching the client, these contractions could cause them to jerk or move suddenly, potentially causing injury to themselves or others.

Safety guidelines: It is a standard safety guideline in all healthcare settings to clear the area around a client before defibrillation to ensure the safety of everyone involved.

I'll now address the other choices, even though they are not the correct answer, to provide a comprehensive understanding:

Choice A rationale:

While ventilation is important during cardiac arrest, it should be temporarily paused during defibrillation. The chest compressions and electrical shock can cause movement of air in the lungs, which can interfere with the effectiveness of the defibrillation. Additionally, the risk of accidental shock to the person providing ventilation is increased if they are close to the client during defibrillation.

Choice C rationale:

Waiting 3 minutes between shocks is not necessary with modern defibrillators. Current guidelines recommend immediate defibrillation for shockable rhythms such as ventricular fibrillation or pulseless ventricular tachycardia. Delaying defibrillation can decrease the chances of successful resuscitation.

Choice D rationale:

The placement of gel pads is important for effective conduction, but it is not the priority action during defibrillation. Ensuring safety by clearing the area and delivering the shock promptly is more critical in the initial moments of defibrillation.