The nurse is educating an older adult patient who is taking antihypertensives with diuretics. Which information regarding safety precautions is most important for the nurse to include?
a. Consider purchasing a home blood pres-sure monitor.
b. Limit sodium intake in the diet.
c. Sit on the side of the bed before standing.
d. Keep an updated list of all medications.
C
Age-related changes (reduced baroreceptor sensitivity) and risk for fluid shifts related to diuret-ics predispose the older adult patient to orthostatic hypotension. In order to prevent falls, the pa-tient should change positions slowly and cautiously, like taking time to sit on the edge of the bed before standing. While purchasing a home blood pressure monitor, limiting sodium in the diet, and keeping an updated list of medications may assist with management of hypertension, fall prevention and safety are most important for the older adult patient.
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The nurse is unable to obtain information from the client and knows the BEST secondary source of client information is which of the following?
a. client c. close friends b. client records d. neighbors
A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during pregnancy. Now, the nurse finds a pulse of 60 beats per minute. Which of these actions should the nurse take?
A) Document the finding, as it is a normal finding at this time. B) Contact the physician, as it indicates early DIC. C) Contact the physician, as it is a first sign of postpartum eclampsia. D) Obtain an order for a CBC, as it suggests postpartum anemia.
The nurse manager wants to evaluate the behavior of the unlicensed personnel. One way the manager can do this is by asking staff nurses to assist in documenting certain behaviors. This is a form of:
a. Anecdotal notes b. Ranking c. Forced distribution scale d. Contrast scale
A client has experienced a cerebrovascular accident (CVA) that resulted in hemiplegia. The client is diagnosed with flaccid stage hemiplegia. Which of the following characterizes this stage of paralysis?
A) Therapy and rehabilitation methods are most successful. B) The affected side exhibits numbness and weakness. C) The muscles are contracted and tense and movement is difficult. D) The affected side is limp and lifeless.