After taking the client's postural vital signs, the student nurse determines that the client has manifested orthostatic hypotension. Which of the following nursing diagnoses can be created? Select all that apply
A) Alteration is rest and comfort
B) Fluid volume deficit
C) Risk for falls
D) Pain
E) Ineffective individual coping
Ans: B, C
Feedback:
Orthostatic blood pressure changes may indicate hypovolemia or a failure of the autonomic nervous system protective reflexes. Hypovolemia or impaired vasoconstriction is signaled by decreased blood pressure and increased heart rate.
The person experiencing orthostatic hypotension is at risk for falling. Therefore, checking postural vital signs is one way of screening to ensure patient safety.
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