An older client tells the home health care practical nurse (PN) about experiencing dizziness when getting out of bed. Which assessment is most important for the PN to obtain?
Oxygen saturation.
Standing blood pressure.
Pulse deficit
Apical heart rate.
The Correct Answer is B
A. Oxygen saturation: Assessing oxygen saturation provides information about respiratory and circulatory efficiency, but dizziness upon standing is more often linked to hemodynamic changes rather than oxygenation issues.
B. Standing blood pressure: Measuring standing blood pressure is most important to assess for orthostatic hypotension, a common cause of dizziness in older adults. A significant drop in blood pressure upon standing indicates impaired vascular response, which increases the risk of falls and injury.
C. Pulse deficit: Evaluating for a pulse deficit helps detect cardiac arrhythmias, but it is not the most relevant initial assessment for postural dizziness. Orthostatic blood pressure changes should be ruled out before exploring other cardiovascular causes.
D. Apical heart rate: While assessing the apical rate can detect irregularities in rhythm, it does not explain dizziness triggered by position changes. Postural blood pressure measurement provides more specific information about the cause of dizziness in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Identify the method for transporting and evacuating each resident: The PN must determine the safest and most effective way to evacuate residents, taking into account mobility limitations, medical equipment needs, and cognitive status. This critical task ensures resident safety and requires professional assessment and decision-making rather than delegation.
B. Offer comfort and reassurance to each resident: Providing emotional support is important during a fire but can be safely delegated to unlicensed assistive personnel (UAP) while the PN focuses on immediate safety measures.
C. Close the doors to all of the residents' rooms: Closing doors can slow fire spread and is a useful action but does not require the clinical judgment of the PN and can be assigned to UAP.
D. Provide blankets to each of the residents for use during evacuation: Distributing blankets helps protect residents during evacuation but is a task that does not require professional decision-making and can be delegated to UAP.
Correct Answer is A
Explanation
A. Upper torso: In older adults, the center of gravity shifts upward toward the upper torso due to changes in posture, muscle mass, and spinal curvature. Recognizing this shift helps the PN use proper body mechanics and prevent falls or musculoskeletal injury when assisting the client.
B. Head: The head contributes to balance but is not the primary location of the center of gravity. Focusing on the head alone would not provide effective guidance for safe mobility assistance.
C. Upper extremities: While upper extremities are important for support and mobility, they do not represent the center of gravity. Relying on arm strength without adjusting posture could compromise safety.
D. Feet: Feet provide the base of support but are not the center of gravity. Proper positioning of the client’s torso and alignment is critical to maintain balance and prevent falls during transfers.
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