Author Question: After taking the client's postural vital signs, the student nurse determines that the client has ... (Read 72 times)

SO00 · **on:** Jul 22, 2018

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

Question 2

The nurse is taking the client's temperature. The nurse understands that the rectal route is one of the most reliable. Which client can safely handle the rectal route of taking temperature?

A) a client who is short of breath just by using the restroom
B) a 9-month old infant who has been crying for the past 2 hours
C) the 65-year old male who just finished drinking coffee
D) the client who is vomiting

ky860224 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

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.

Answer to Question 2

Ans: C
Feedback:
Hot or cold drinks may cause variations in oral temperature readings. Diaphoresis or air blowing over the face may affect temporal artery measurements; stool in the rectum can affect rectal temperatures.