A male client age 78, complaints of dizziness, especially when he stands up after sleeping or sitting. The client also informs the nurse that he periodically experiences nosebleeds and blurred vision. Which of the ff conditions should the nurse assess for the client?

Correct Answer: A

Rationale: The client's symptoms of dizziness upon standing up, along with nosebleeds and blurred vision, are suggestive of postural hypotension. Postural hypotension, also known as orthostatic hypotension, is a drop in blood pressure that occurs when a person stands up from a sitting or lying position. This drop in blood pressure can lead to symptoms such as dizziness, lightheadedness, blurred vision, and in some cases, nosebleeds. It is more common in older adults, like the 78-year-old male client in this scenario. Therefore, the nurse should assess for postural hypotension in this client to manage his symptoms and prevent complications.

Correct Answer: D

Rationale: Diabetes insipidus is a condition characterized by the inability of the kidneys to conserve water, leading to excessive urination and extreme thirst. The main treatment for diabetes insipidus is the administration of vasopressin (also known as antidiuretic hormone or ADH). Vasopressin helps the kidneys retain water, reduce urine output, and stabilize the body's fluid balance. Therefore, in caring for a client with diabetes insipidus, the nurse should anticipate the administration of vasopressin to help manage the symptoms of excessive urination and dehydration.

Correct Answer: A

Rationale: Voluntary release is a key milestone in visuomotor coordination at this age.

Correct Answer: C

Rationale: A positive Homans' sign indicates possible deep vein thrombosis (DVT) in the leg. When a patient has DVT, the clot may dislodge and travel to the lungs, causing a pulmonary embolism, which can be life-threatening. Therefore, ambulation and performing the Homans' sign can dislodge the clot and potentially cause an embolism. It is contraindicated to prevent this serious complication.

Correct Answer: A

Rationale: Adequate cardiac output is a measure of how well the heart is able to pump blood effectively to meet the body's metabolic demands. An adequate cardiac output ensures sufficient oxygen and nutrients are delivered to the tissues and organs. One of the most reliable indicators of adequate cardiac output is urine output. A urine output of at least 1 mL/kg/hour, which translates to around 30 mL/hour in a 5-year-old child, indicates adequate perfusion and renal function. In heart failure, decreased cardiac output may lead to decreased renal perfusion, resulting in a decreased urine output, so a stable or increased urine output suggests adequate cardiac output.