The nurse is admitting a client who has had a syncopal episode at home. The client's BP is 120/88. The client has a history of hypertension and reports that the healthcare provider has increased their antihypertensive medication recently. What should the nurse do next?
Check urine for ketones
Obtain orthostatic blood pressure
Decrease the dose of the antihypertensive
Monitor intake
The Correct Answer is B
A. Check urine for ketones — Ketone testing is typically relevant for clients with diabetes or suspected ketoacidosis, not for evaluating causes of syncope in a hypertensive client.
B. Obtain orthostatic blood pressure — A recent increase in antihypertensive medication may cause orthostatic hypotension, which can lead to syncope (fainting). Measuring orthostatic vital signs (BP and HR in lying, sitting, and standing positions) helps assess this risk and guides further intervention.
C. Decrease the dose of the antihypertensive — Nurses cannot independently alter medication doses without a provider's order. The nurse should assess and report findings before any changes are made.
D. Monitor intake — While monitoring fluid intake is important, it is not the immediate priority in evaluating a syncopal episode potentially related to medication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Clients with heart failure typically require more frequent follow-up than twice a year, especially after a new diagnosis.
B. Activity restriction is not generally encouraged unless the client is symptomatic; regular physical activity (as tolerated) is beneficial in managing heart failure.
C. Nitroglycerin patches are not typically used for sudden chest pain; sublingual nitroglycerin is used for acute episodes.
D. A weight gain of 6 pounds (from 124 to 130 pounds) in one week may indicate fluid retention and worsening heart failure. Promptly notifying the healthcare provider is appropriate and demonstrates effective understanding of self-monitoring and management.
Correct Answer is D
Explanation
A. Pneumocystis lung infection — This is an opportunistic infection that occurs in later stages of HIV (AIDS), not during the initial phase.
B. Fungal and bacterial infections — These typically develop as the immune system becomes severely compromised, which happens in the later stages of HIV progression.
C. Kaposi's sarcoma — This is a type of cancer associated with AIDS and indicates advanced disease, not early HIV infection.
D. Flu-like symptoms and night sweats — These are common initial symptoms of acute HIV infection and occur during the seroconversion phase. Other early symptoms may include fever, sore throat, fatigue, and swollen lymph nodes.
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