The patient has a history of orthostatic hypotension. What is the priority action of the nurse?
Always take the patient's blood pressure manually using a sphygmomanometer.
Monitor the patient's neurological status carefully for symptoms of a stroke.
Assist the patient to sit and stand slowly when getting out of bed.
Check the patient's blood pressure on a lower extremity using a thigh-sized cuff.
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Ask the client to take deep breaths. Deep breathing can help relax the anal sphincter, but if resistance is already encountered, forcing the thermometer further could cause injury.
B. Remove the thermometer and reinsert more forcefully. Forcing the thermometer can cause damage to the rectal mucosa, leading to pain, bleeding, or even perforation.
C. Apply mild pressure to advance. Any resistance suggests a possible obstruction, such as stool or anatomical issues. Applying pressure could cause harm, so the thermometer should not be advanced further.
D. Remove the thermometer immediately. If resistance is encountered, the safest action is to withdraw the thermometer to prevent injury. The nurse should reassess the situation and consider alternative temperature measurement methods.
Correct Answer is B
Explanation
A. Posterior-to-anterior comparison. While both the anterior and posterior lung fields should be assessed, auscultation should be performed in a systematic side-to-side manner rather than switching between front and back.
B. Side-to-side comparison. The correct method for auscultating breath sounds is to compare sounds bilaterally (right lung to left lung) at each level. This helps identify asymmetrical lung sounds, which could indicate conditions like pneumonia, pleural effusion, or atelectasis.
C. Top-to-bottom comparison. While lung auscultation progresses from the apices to the bases, it should always be done in a side-to-side manner to detect differences between the lungs.
D. Interspace-by-interspace comparison. Although breath sounds are assessed at different intercostal spaces, the key principle is to compare sounds bilaterally at each level, rather than focusing solely on individual interspaces.
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