A nurse is caring for a client who has postural hypotension. The nurse assists the client gradually from a lying down to standing position. The nurse should identify that which of the following findings indicates the intervention is effective?
The client’s systolic blood pressure decreases from 110 mm Hg to 105 mm Hg.
The client reports nausea.
The client’s heart rate increases from 100/min to 108/min.
The client reports dizziness.
The Correct Answer is A
Postural hypotension, also known as orthostatic hypotension, is a form of low blood pressure that occurs when standing up from a sitting or lying down position 1. An effective intervention for postural hypotension would be one that helps to prevent a significant drop in blood pressure when the client changes position. A small decrease in systolic blood pressure, such as from 110 mm Hg to 105 mm Hg, would indicate that the intervention is effective in preventing a larger drop in blood pressure.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
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)
Correct Answer is D
Explanation
The first step in the inflammatory response is the recognition of harmful stimuli by pattern recognition receptors (PRRs) on the surfaces of various cells, including immune cells and non-immune cells. PRRs recognize specific patterns associated with pathogens, damage-associated molecular patterns (DAMPs), and pathogen-associated molecular patterns (PAMPs), among others. This recognition leads to the activation of signaling pathways that promote the recruitment and activation of immune cells and the release of inflammatory mediators, such as cytokines and chemokines.
Once the PRRs recognize the harmful stimuli, inflammatory cells are activated, including neutrophils, macrophages, and dendritic cells. These cells then release inflammatory markers, such as C-reactive protein, which promote the recruitment and activation of more immune cells and further amplify the inflammatory response. Inflammatory pathways are also triggered, leading to the production of various inflammatory mediators and the activation of transcription factors that regulate the expression of genes involved in the inflammatory response.
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