The care plan of an older adult patient states that the patient should be monitored while in the bathroom because of a history of vasovagal reflex. What should the nurse assess with this pa-tient?
a. Extremely elevated blood pressure after ambulation
b. Nausea and vomiting after a meal
c. Lightheadedness and fainting during de-fecation
d. Inability to urinate
C
Constipated individuals may strain to defecate, causing an increase in intraabdominal pressure. This is called the Valsalva maneuver or vasovagal reflex, and it can lead to cardiovascular altera-tions.
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