Examkin

Soru

Zorluk: OrtaReduction of Risk Potential

A practical nurse (PN) is preparing to measure orthostatic vital signs for an older adult client who reports experiencing dizziness when getting out of bed. Arrange the following steps in the correct sequence the PN should follow to safely and accurately assess for orthostatic hypotension.

  1. 1Have the client lie flat in a supine position for 5 to 10 minutes.
  2. 2Measure and record the baseline blood pressure and pulse rate.
  3. 3Assist the client to an upright standing position.
  4. 4Wait 1 to 3 minutes while observing the client for symptoms.
  5. 5Re-measure the blood pressure and pulse in the standing position.

Cevap

The correct sequence is to first have the client lie supine for 5 to 10 minutes, measure the baseline vitals, assist the client to a standing position, wait 1 to 3 minutes, and finally re-measure the vitals in the standing position.
Measuring orthostatic vital signs accurately requires a strict protocol to detect orthostatic hypotension safely. The client must first rest supine to establish a true baseline. After taking these baseline measurements, the client is assisted to a standing position. Gravity causes blood to pool in the lower extremities, and the nurse must wait 1 to 3 minutes to see if the autonomic nervous system properly compensates. Finally, re-measuring the vitals will reveal if there is a significant, sustained drop in blood pressure or an abnormal increase in heart rate.

Adım Adım Çözüm

1
Ensure the client rests in a supine position for 5 to 10 minutes.
The cardiovascular system reaches a resting baseline state.
Accurate comparison requires a stable, resting baseline before initiating positional changes.
2
Measure and record the blood pressure and pulse rate.
Baseline vital signs are established.
These values serve as the control to determine if subsequent positional changes cause abnormal deviations.
3
Assist the client to a standing position.
Gravity causes a sudden fluid volume shift toward the lower extremities.
Standing triggers the baroreceptor reflex, which tests the autonomic nervous system's ability to compensate for the positional change.
4
Wait 1 to 3 minutes after the position change.
The body is given time to compensate for the fluid shift.
Taking vitals too quickly can yield false results, as the cardiovascular system needs a brief period to adjust to the gravitational pull.
5
Measure and record the standing blood pressure and pulse rate.
Standing vital signs are obtained.
Comparing these values to the baseline identifies orthostatic hypotension, which is typically defined as a drop in systolic blood pressure of 20 mm Hg or more, or diastolic blood pressure of 10 mm Hg or more.

Anahtar Kavram

Orthostatic Vital Signs Assessment Protocol
Tahmini Süre:1m 30s
Bu soruyu puanla

Konular

Reduction of Risk Potential

Bu konudan daha fazla soru