An older adult client receiving medication for hypertension had a recent fall at home. Which intervention should the nurse include in this client's plan of care?
A) Monitor serum sodium levels.
B) Assess postural blood pressures.
C) Monitor serum creatinine levels.
D) Monitor blood pressure every 2 hours.
Answer: B
Baroreceptors are less efficient with aging. Therefore, orthostatic hypotension is more likely to occur. Also, clients treated for hypertension could have an increase in sensitivity to the medications. Postural blood pressure assessment allows the nurse to prevent orthostatic hypotension and falls. Every 2 hours is too frequent for assessments of a noncritical client. Sodium intake and creatinine levels assess renal function.
You might also like to view...
A patient who is 5 feet 9 inches tall and weighs 160 pounds believes that her size-9 feet are enormous compared with the rest of her body
She has visited orthopedic surgeons to see if surgery could reduce the length of her feet, and she spends hours trying to buy shoes that make her feet look smaller. In social situations, she sits with her feet concealed under a table or wears long skirts to hide them. The nurse can assess that the patient's symptoms are consistent with: a. hypochondriasis. b. somatoform pain disorder. c. body dysmorphic disorder. d. depersonalization disorder.
The nurse caring for a client with acute renal failure realizes that a complication has occurred during the diuretic stage of the disorder when the client exhibits signs of: Select all that apply
1. Hypovolemia. 2. Hypotension. 3. Infection. 4. Hyperkalemia. 5. Hypernatremia.
When caring for a patient who has just arrived on the medical-surgical unit after having cardiac catheterization, which nursing intervention should the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)?
a. Give the scheduled aspirin and lipid-lowering medication. b. Perform the initial assessment of the catheter insertion site. c. Teach the patient about the usual postprocedure plan of care. d. Titrate the heparin infusion according to the agency protocol.
You are assisting with post-mortem care. The body produces sounds during turning and re-positioning. Which is correct?
a. The person is still alive. b. CPR must be started. c. The sounds are normal and expected. d. The sounds are signs of rigor mortis.