Final answer:
The patient's symptoms suggest orthostatic hypotension, a condition where blood pressure drops upon standing. The recommended nursing action includes monitoring and potentially increasing fluid intake to manage the condition.
Step-by-step explanation:
The scenario described involves a patient with symptoms that include weakness, confusion, dizziness upon standing, with various vital signs such as elevated temperature, heart rate, respiratory rate, and a blood pressure reading that is on the lower end of normal. These symptoms and signs could indicate a condition known as orthostatic hypotension, which is a form of low blood pressure that happens when standing up from sitting or lying down. This can lead to lightheadedness or dizziness because the brain is temporarily receiving less blood and therefore less oxygen.
Orthostatic hypotension can occur if there is not enough blood volume (hypovolemia) for the body to increase blood pressure adequately upon standing. This can be due to dehydration or the effects of certain medications, like diuretics or vasodilators, which can lower blood pressure. To manage this condition, the nurse should monitor the patient for further signs of orthostatic hypotension and consider intervention strategies such as increasing fluid intake or recommending changes to medication if these are contributing to the patient's condition.