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 A
Explanation
A. Wear closed-toe shoes that are comfortable and fit well: Wearing well-fitting shoes helps prevent foot injuries and complications, which are common in people with diabetes due to neuropathy and poor circulation. Foot care is crucial for diabetes management.
B. Obtain an A1C blood test every year to monitor glucose control: The A1C test should be done at least twice a year if the client’s blood sugar is under control, or more often if adjustments are needed.
C. Check blood sugar levels every four to six hours every day: Most individuals with type 2 diabetes need to check blood sugar based on specific times like before meals or once daily, not every few hours.
D. Restrict alcoholic beverages to no more than 1 to 2 per week: Moderate alcohol intake may be allowed in some cases, but more frequent consumption can affect blood sugar. The goal is to limit intake, not restrict to a specific number per week.
Correct Answer is D
Explanation
A. Ask if the client is experiencing any change in bowel habits: Changes in bowel habits are not directly related to the confusion or memory loss seen in pernicious anemia. The concern here is primarily with vitamin B12 deficiency.
B. Determine if the client is taking iron and folic acid supplements: While iron and folic acid are important, they don't directly address the memory loss and confusion related to B12 deficiency. The immediate focus should be on the effects of the B12 treatment.
C. Encourage the husband to bring the client to the clinic for a complete blood count: A CBC can help monitor anemia, but it doesn't address the memory issues. The nurse should first explain the symptoms related to B12 deficiency.
D. Explain that memory loss and confusion are common with vitamin B12 deficiency:
Memory loss and confusion are known symptoms of vitamin B12 deficiency. These symptoms may take time to improve with treatment, and educating the husband helps alleviate concerns.
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