The nurse in the long-term care facility is caring for an 88-year-old female client.
0650:Unlicensed assistive personnel (UAP) reports that the client became lightheaded when helped to stand for the bathroom and sat back down on the bed. No fall. The furosemide dose was increased 3 days ago.
0705:Lying and standing blood pressures taken (see Vital Signs). Lightheaded again after 1 minute of standing; the feeling cleared after sitting. Alert and oriented. Face symmetrical, speech clear, hand grips equal. Skin warm and dry. Fasting point-of-care glucose 96 mg/dL (reference range 70–99 mg/dL). Hemoglobin last week 12.8 g/dL (reference range for females 12–16 g/dL). Non-slip socks on, call light within reach. The UAP asks whether a vest restraint should be used when the client sits in the chair.
The nurse is reviewing the client's assessment data to prepare the client's plan of care.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Action to TakeAction to Take
Condition Most Likely ExperiencingParameter to MonitorParameter to Monitor
Actions to Take
Activate the stroke response team.
Give 15 g of fast-acting carbohydrate.
Teach the client to change position slowly.
Request a pharmacist review of the medications.
Apply a vest restraint while the client is in the chair.
Potential Conditions
anemia
hypoglycemia
orthostatic hypotension
transient ischemic attack
Parameters to Monitor
blood glucose
facial symmetry
hemoglobin level
dizziness on standing
lying and standing blood pressure