A client's most recent vital signs include heart rate 80 beats/minute and blood pressure 119/70 mm Hg. When the client reports dizziness after rising quickly, which finding should the nurse expect on reassessment?
Heart rate 100 beats/minute.
Blood pressure 125/65 mm Hg.
Heart rate 70 beats/minute.
Blood pressure 115/70 mm Hg.
The Correct Answer is A
A. Heart rate 100 beats/minute: A compensatory increase in heart rate (tachycardia) is expected in orthostatic hypotension. It helps maintain cerebral perfusion when blood pools in the lower extremities after standing quickly.
B. Blood pressure 125/65 mm Hg: This BP shows a slight systolic increase, which is not typical after orthostatic stress. A decrease in BP, not an increase, would be expected if symptoms like dizziness are present.
C. Heart rate 70 beats/minute: A decreased heart rate is not physiologically expected when someone experiences postural hypotension. Bradycardia would worsen cerebral perfusion and is inconsistent with dizziness.
D. Blood pressure 115/70 mm Hg: This change is too minor to explain dizziness. In orthostatic hypotension, we usually expect a drop of ≥20 mm Hg systolic or ≥10 mm Hg diastolic after position change.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.6"]
Explanation
Rationale:
- Convert the client's weight from pounds (lb) to kilograms (kg).
Weight in kg = 154 lb / 2.2 lb/kg
= 70 kg.
- Calculate the total desired dose in units.
Desired dose (units) = Desired dose (units/kg) × Weight (kg)
= 200 units/kg × 70 kg
= 14000 units.
Available concentration of the medication = 25,000 units/mL.
- Calculate the volume in milliliters (mL) to administer.
Volume (mL) = Desired dose (units) / Available concentration (units/mL)
= 14000 units / 25000 units/mL
= 0.56 mL.
- Round the answer to the nearest tenth.
= 0.6.
Correct Answer is A
Explanation
A. "Risk for self-directed violence as evidenced by feelings of hopelessness": The client’s feelings of hopelessness, combined with significant weight loss and loss of interest in activities, suggest possible depression. Hopelessness is a key symptom of depression, which can increase the risk for self-harm or suicide.
B. "Chronic low self-esteem as evidenced by feelings of worthlessness": Feelings of worthlessness are part of the larger picture of the client’s depression. The priority is to address the immediate risk of harm, which takes precedence over chronic low self-esteem.
C. "Anxiety as evidenced by abdominal discomfort secondary to depression": While abdominal discomfort can be a symptom of depression, it is secondary to the more immediate concern of the client’s potential risk for self-directed violence.
D. "Imbalanced nutrition as evidenced by 25 lb (11 kg) weight loss in four months": The significant weight loss is concerning, but it is likely a result of the client’s depression. The focus should first be on addressing the client’s safety, followed by nutrition and weight restoration.
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