During a physical examination, the nurse observes spoon-shaped nails (koilonychia). Which condition should the nurse suspect?

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.

Rationale:

A. The jugular veins should not be visibly distended when the client is sitting upright. Visible jugular vein distention in this position can indicate increased central venous pressure or heart failure, which is an abnormal finding.

B. Tenderness when palpating the thyroid gland is not expected. A healthy thyroid is typically non-tender. Pain or tenderness may indicate inflammation, infection (thyroiditis), or other pathology requiring further evaluation.

C. A visibly enlarged thyroid gland is abnormal. Enlargement (goiter) may indicate thyroid dysfunction, iodine deficiency, or other endocrine disorders, and is not considered an expected finding in a healthy client.

D. Full range of motion of the neck without pain or stiffness is an expected finding. This indicates normal musculoskeletal function of the cervical spine and surrounding structures, which is consistent with a healthy assessment.