A nurse is caring for a client who is taking antihypertensive medication and is moving from a supine to a sitting position.
Which of the following findings should indicate to the nurse that the client is experiencing orthostatic hypotension?

The client's heart rate increases by 10/min.

The client's diastolic blood pressure increases by 10 mm Hg.

The client reports heart palpitations.

The client's systolic blood pressure decreases by 25 mm Hg.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

An increase in heart rate by 10 beats per minute when moving from a supine to a sitting position is a normal physiological response to compensate for decreased venous return and maintain cardiac output. This response does not indicate orthostatic hypotension.

Choice B rationale:

An increase in diastolic blood pressure by 10 mm Hg when moving from a supine to a sitting position is a normal response to compensate for the effects of gravity on blood flow. It helps maintain perfusion to vital organs and does not indicate orthostatic hypotension.

Choice C rationale:

Heart palpitations can occur due to various reasons, including anxiety or arrhythmias, but they are not specific signs of orthostatic hypotension. This symptom alone does not confirm the presence of orthostatic hypotension.

Choice D rationale:

A decrease in systolic blood pressure by 25 mm Hg or more when moving from a supine to a sitting position indicates orthostatic hypotension. Orthostatic hypotension is defined as a drop in systolic blood pressure of 20 mm Hg or more or a drop in diastolic blood pressure of 10 mm Hg or more within 3 minutes of standing up. This condition can cause dizziness, lightheadedness, or fainting and can be a side effect of antihypertensive medications or other underlying medical conditions.

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Correct Answer is C

Explanation

Choice A rationale:

Applying sterile gloves when changing the ostomy pouch is essential for infection control. However, this is a standard practice and not specific to the client's condition. While important, it is not the priority instruction for a client with a new ostomy.

Choice B rationale:

Notifying the provider if the stoma becomes pink and moist is crucial information for the client. A pink and moist stoma indicates good blood supply and healing, while changes in color or moisture might indicate complications. This instruction is essential for the client's ongoing care and to prevent potential complications, making choice B the correct answer.

Choice C rationale:

Emptying the ostomy pouch when it is half full is a general guideline to prevent leakage and maintain hygiene.

Choice D rationale:

Soaps with lotions or perfumes may interfere with the pouch seal or cause peristomal skin irritation. Rinse and dry well.

A. "My baby should always start on the same breast when feeding." B. "Manually expressing my milk will decrease my milk supply." C. "The more my baby is at the breast sucking, the more milk I will produce." D. "After 5 to 10 minutes when the breast is emptied, my baby should be removed from the breast."

Correct Answer is C

Explanation

A. Incorrect. It's important to alternate breasts during feedings to ensure both breasts are stimulated and milk supply is well-maintained.
B. Incorrect. Manually expressing milk can help stimulate milk production and maintain milk supply; it typically does not decrease milk supply.
C. Correct. Frequent and effective breastfeeding, along with proper latching and milk removal, stimulates the production of more milk.
D. Incorrect. Breastfeeding should continue for as long as the baby is actively sucking and swallowing. Babies vary in their feeding patterns, and the length of time at each breast can differ. It's essential to ensure the baby is adequately fed and empties the breast to stimulate milk supply.

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A nurse is caring for a client who is taking antihypertensive medication and is moving from a supine to a sitting position.Which of the following findings should indicate to the nurse that the client is experiencing orthostatic hypotension?

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A nurse is caring for a client who is taking antihypertensive medication and is moving from a supine to a sitting position.
Which of the following findings should indicate to the nurse that the client is experiencing orthostatic hypotension?