Exhibits

Lana is developing Mrs. Watson's care plan. She wants to add more interventions and not just deliver pain medication. What are some other nursing actions that would be helpful to Mrs. Watson? Select the 4 correct answers (Case Study #2)

A. Always take the patient's blood pressure manually using a sphygmomanometer. While manual BP measurements can be more accurate, they are not the priority intervention for orthostatic hypotension, which primarily involves position changes and fall prevention.
B. Monitor the patient's neurological status carefully for symptoms of a stroke. Orthostatic hypotension can cause dizziness or fainting, but it is not a direct cause of stroke. Neurological assessment is important if symptoms arise but is not the primary intervention.
C. Assist the patient to sit and stand slowly when getting out of bed. Orthostatic hypotension causes a sudden drop in blood pressure upon standing, increasing the risk of falls and syncope. The priority action is to help the patient transition slowly from lying to sitting and standing to allow the body to adjust.
D. Check the patient's blood pressure on a lower extremity using a thigh-sized cuff. Lower extremity BP measurements are not standard for managing orthostatic hypotension. Blood pressure should be checked in both lying, sitting, and standing positions to monitor for significant drops.

A. The patient's blood pressure must remain elevated during several separate assessments in order to make a diagnosis of hypertension. Hypertension is diagnosed based on persistently elevated blood pressure readings across multiple visits, rather than a single elevated measurement.
B. The patient appeared extremely stressed and the health care provider decided not to inform the patient of the diagnosis at that appointment. While stress can temporarily elevate blood pressure, a diagnosis should be based on multiple readings rather than withholding information from the patient.
C. The patient's primary health care provider must consult with a cardiologist in order to make a diagnosis of hypertension. A cardiology consult is not required to diagnose hypertension; primary care providers can diagnose and manage hypertension independently.
D. The patient's blood pressure must be at least 180/100 during a single assessment in order for a diagnosis of hypertension to be made. A reading of 180/100 mmHg indicates hypertensive crisis, but hypertension is diagnosed when blood pressure is consistently ≥140/90 mmHg on multiple occasions.