Question

The care plan of an older adult patient states that the patient should be monitored while in the bathroom because of a history of vasovagal reflex. What should the nurse assess with this patient?

a. Extremely elevated blood pressure after ambulation

b. Nausea and vomiting after a meal

c. Lightheadedness and fainting during defecation

d. Inability to urinate

Answer 1

The care plan of an elderly patient with a history of vasovagal reflex calls for monitoring in the bathroom to assess for lightheadedness and fainting during defecation due to the risk of a sudden drop in heart rate and blood pressure.

Step-by-step explanation:

The care plan of an older adult patient stating that they should be monitored while in the bathroom due to a history of vasovagal reflex would require the nurse to assess for c. Lightheadedness and fainting during defecation. The vasovagal reflex can lead to a sudden drop in heart rate and blood pressure, resulting in dizziness or fainting, especially in situations like straining during bowel movements. It is important to monitor these patients to ensure their safety and help prevent falls or other injuries associated with fainting spells.