A patient reports dizziness when standing two days after starting treatment for hypertension. The patient is alert, has no chest pain, and is currently sitting safely. What should the nurse do first?
Correct answer: B. Assess the blood pressure and pulse lying and standing
- A. Assist the patient to stand without support
- B. Assess the blood pressure and pulse lying and standing
- C. Tell the patient to stop the medication immediately
- D. Encourage the patient to walk until the dizziness settles
Explanation
The symptoms may reflect postural hypotension, so the nurse should assess lying and standing vital signs while preventing a fall. The nurse should not independently stop prescribed treatment or ask the patient to walk while dizzy.
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About Clinical Judgement and Prioritisation
Clinical judgement links assessment findings, nursing knowledge and patient responses to a safe decision. Coverage includes ABCDE assessment, recognising actual or potential instability, prioritising airway, breathing and circulation, using urgency and risk rather than routine order, reassessing after intervention, and distinguishing a nursing priority from a medical diagnosis or a task that can wait.
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