A nurse is assessing a client for orthostatic hypotension. Which of the following actions should the nurse take first?
Check the blood pressure with the client in a supine position.
Place the client in a sitting position.
Assist the client into a standing position.
Determine the client’s blood pressure 1 min after each position change.
The Correct Answer is A
Orthostatic hypotension is defined as a decrease in blood pressure of 20 mm Hg or more systolic or 10 mm Hg or more diastolic within three minutes of standing from the supine position1. The first step in assessing a client for orthostatic hypotension is to check their blood pressure while they are lying down (supine position)
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
When taking an electronic blood pressure measurement, it is important to properly position the cuff on the client’s arm. The artery indicator on the blood pressure cuff should be aligned with the client’s brachial artery1. It is also important to select a cuff that fits properly and to have the client sit comfortably with their back supported and feet flat on the ground2.
Correct Answer is A
Explanation
Pain can cause an increase in sympathetic nervous system activity, leading to vasoconstriction and increased heart rate, which can result in hypertension. Pain may also increase the release of stress hormones, such as cortisol and epinephrine, which can further contribute to increased blood pressure.
Bradycardia (slow heart rate) decreased respiratory rate, and hypoglycemia are not typical findings associated with acute pain.
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