The nurse's assessment of an older adult client reveals the following data: Lying BP 144/82 mm Hg; sitting BP 121/69 mm Hg; standing BP 98/56 mm Hg. The nurse should consequently identify what nursing diagnosis in the patient's plan of care?
A) Risk for ineffective breathing pattern related to hypotension
B) Risk for falls related to orthostatic hypotension
C) Risk for ineffective role performance related to hypotension
D) Risk for imbalanced fluid balance related to hemodynamic variability
Ans: B
Feedback:
Orthostatic hypotension creates a significant risk for falls due to the dizziness and lightheadedness that accompanies it. It does not normally affect breathing or fluid balance. The patient's ability to perform normal roles may be affected, but the risk for falls is the most significant threat to safety.
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