A nurse is preparing to assess a patient for orthostatic ...

[darbym82]

A nurse is preparing to assess a patient for orthostatic hypotension. Which piece of equipment will the nurse obtain to assess for this condition?
 
  a. Thermometer
  b. Elastic stockings
  c. Blood pressure cuff
  d. Sequential compression devices

Question 2

The patient has been in bed for several days and needs to be ambulated. Which action will the nurse take first?
 
  a. Maintain a narrow base of support.
  b. Dangle the patient at the bedside.
  c. Encourage isometric exercises.
  d. Suggest a high-calcium diet.

[wfdfwc23]

Answer to Question 1

ANS: C
A blood pressure cuff is needed. Orthostatic hypotension is a drop of blood pressure greater than 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure and symptoms of dizziness, light-headedness, nausea, tachycardia, pallor, or fainting when the patient changes from the supine to standing position. A thermometer is used to assess for fever. Elastic stockings and sequential compression devices are used to prevent thrombus.

Answer to Question 2

ANS: B
To prevent injury, nurses implement interventions that reduce or eliminate the effects of orthostatic hypotension. Mobilize the patient as soon as the physical condition allows, even if this only involves dangling at the bedside or moving to a chair. A wide base of support increases balance. Isometric exercises (i.e., activities that involve muscle tension without muscle shortening) have no beneficial effect on preventing orthostatic hypotension, but they improve activity tolerance. A high-calcium diet can help with osteoporosis but can be detrimental in an immobile patient.