# A 78-year-old client with heart failure and diabetes is taking 12 different medications. The nurse is conducting a medication reconciliation review. Which finding should be the nurse's highest priority concern? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541815 > language: ko > subject: Growth & Development ## 문제 A 78-year-old client with heart failure and diabetes is taking 12 different medications. The nurse is conducting a medication reconciliation review. Which finding should be the nurse's highest priority concern? ## 보기 1. The client reports feeling dizzy and unsteady when getting up from bed in the morning **✔ 정답** 2. The client has difficulty opening childproof medication bottles 3. The client takes medications at slightly different times each day 4. The client stores medications in a weekly pill organizer **정답: 1** ## 해설 Dizziness and unsteadiness (orthostatic hypotension) is the highest priority as it significantly increases fall risk in older adults. Other findings like difficulty opening bottles or variable timing are safety concerns but less urgent. ## 심화 해설 Clinical Context and Priority Setting In geriatric clients with multimorbidity and polypharmacy, adverse drug events (ADRs) are a leading cause of preventable harm. The nurse's role in medication reconciliation extends beyond verifying a list of drugs; it requires a clinical judgment scan to identify the most immediate threat to physiological safety. While all findings in the options represent practical challenges, the nurse must apply a hierarchy of needs, prioritizing hemodynamic stability and fall risk over convenience or organizational issues. Analysis of the Correct Answer (Option 1) The client's report of orthostatic hypotension—feeling dizzy and unsteady upon rising—is the highest priority. This symptom is a direct manifestation of a potential adverse drug reaction (ADR), a risk that is exponentially increased in the elderly due to altered pharmacokinetics and pharmacodynamics . Given the client’s history of heart failure and diabetes, the medication list likely includes vasodilators, diuretics, or antihypertensives, which are high-risk agents for causing postural hypotension. The immediate danger is a fall with resultant fracture or intracranial hemorrhage, which can precipitate a fatal cascade in a 78-year-old. This aligns with the evidence that older adults are a "special population" with greater vulnerability to ADRs, often because drug doses tested in clinical trials are not tolerated by frail, multimorbid patients in the real world . Furthermore, a pharmacist-led medication reconciliation study in the emergency department confirmed that polypharmacy and potentially inappropriate medications (PIMs) are highly prevalent and directly linked to complex, unstable clinical presentations . The nurse must act on this finding immediately by holding potentially causative medications and implementing safety precautions. Analysis of Incorrect Options Option 2 (Difficulty opening childproof bottles) is a functional limitation related to dexterity, often caused by arthritis or neuropathy. While it poses a risk for non-adherence, it is a long-term management issue that can be solved with non-childproof caps. It does not represent an immediate, life-threatening physiological instability. Option 3 (Slightly different administration times) introduces variability in serum drug concentrations. For most maintenance medications, minor timing deviations are less critical than a severe ADR. The exception would be time-sensitive drugs like levodopa or rapid-acting insulin, but even then, the risk of a sudden hypotensive episode takes precedence. Option 4 (Storing medications in a weekly organizer) is actually a positive, safe behavior that reduces the risk of accidental omission or duplication. Clinical decision support systems designed for safer prescribing in older adults aim to reduce complexity, and a pill organizer is a practical tool to manage regimen complexity . This finding is a strength, not a concern. Pathophysiological and Clinical Integration The heightened risk profile in this client is explained by the convergence of polypharmacy and age-related physiological decline. The EU(7)-PIM and EURO-FORTA frameworks, used in advanced clinical decision support tools, explicitly flag medications that are potentially inappropriate in geriatric patients precisely because they cause issues like orthostasis . Moreover, a prospective cohort study on medication errors post-discharge highlighted that changes to cardiometabolic medications—antihypertensives and glucose-lowering agents—are common and frequently lead to adverse events if not carefully reconciled and monitored . The nurse’s clinical judgment must synthesize these data points: a dizzy patient on 12 medications with heart failure and diabetes is statistically and clinically at high risk for a preventable ADR, making this the unequivocal priority over mechanical or scheduling concerns. ## 임상 시나리오 Clinical Practice Guide: Orthostatic Hypotension in Polypharmacy Assessment - Screen all older adults on multiple medications for dizziness or unsteadiness upon standing, especially those on antihypertensives, diuretics, or vasodilators. - Measure orthostatic vital signs: supine BP/HR, then repeat at 1 and 3 minutes after standing. A positive result is a systolic drop ≥20 mmHg or diastolic drop ≥10 mmHg. - Review medication list for drugs that can induce or worsen orthostasis: alpha-blockers, beta-blockers, calcium channel blockers, diuretics, nitrates, and tricyclic antidepressants. Immediate Nursing Actions - Instruct the client to rise slowly from supine to sitting, dangle legs at the bedside for 1–2 minutes before standing, and avoid sudden postural changes. - Advise the client to perform ankle pumps and hand clenches before standing to promote venous return. - Evaluate the home environment for fall hazards (loose rugs, poor lighting) and recommend grab bars in the bathroom. - Report findings to the prescribing provider for potential medication dose adjustment or timing changes (e.g., taking diuretics in the morning). Long-Term Management and Education - Educate on adequate hydration and avoiding alcohol, which can exacerbate hypotension. - Discuss compression stockings if venous pooling is a contributing factor. - Reinforce the importance of never skipping prescribed medications without consultation, as abrupt withdrawal of some agents can cause rebound hypertension and worsen instability. - Schedule follow-up for repeat orthostatic vital sign measurement and fall risk reassessment. ## 핵심 개념 - **Orthostatic Hypotension** — A drop in systolic BP ≥20 mmHg or diastolic BP ≥10 mmHg within 3 minutes of standing, often causing dizziness, and linked to increased fall risk in older adults. - **Medication Reconciliation** — A formal process of comparing a patient's current medication orders to all medications the patient has been taking to identify and resolve discrepancies and safety risks. - **Polypharmacy** — The concurrent use of multiple medications, commonly defined as five or more, which increases the risk of adverse drug events, interactions, and geriatric syndromes like falls. ## 같은 주제 문제 - [An 82-year-old client with multiple chronic conditions is prescribed several new medicatio…](https://mymerci.kr/pages/nclex_q.php?qn_id=541814) - [An 82-year-old client with multiple chronic conditions is taking 12 different medications.…](https://mymerci.kr/pages/nclex_q.php?qn_id=541816) - [An 82-year-old client with multiple chronic conditions is prescribed several new medicatio…](https://mymerci.kr/pages/nclex_q.php?qn_id=541817) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._