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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A toddler running with a wide stance is a common behavior at this age and does not necessarily indicate developmental delay. Toddlers often develop a wide base of support as they learn to balance and walk more confidently.
Choice B rationale:
Falling when throwing a ball overhand requires coordination and motor skills. By the age of 24 months, most toddlers can throw a ball with some degree of accuracy. Inability to do so may indicate a developmental delay in motor skills, making choice B the correct answer.
Choice C rationale:
Referring to oneself by name is a typical language development milestone around the age of 24 months. It demonstrates a basic understanding of self-identity and language, indicating appropriate developmental progress. This choice does not suggest a delay.
Choice D rationale:
Going up stairs with two feet on each step is a gross motor skill that toddlers typically develop around 36 months of age. It requires balance and coordination. While it is advanced for a 24-month-old, it is not necessarily a sign of developmental delay. Therefore, this choice does not provide a clear indication of delay.
Correct Answer is ["A","C","D","G"]
Explanation
A. "Try using an abdominal support belt." - An abdominal support belt is recommended to provide support to the growing abdomen and can help alleviate backaches that are common during pregnancy.
B. "Take hot showers to help relieve itching." - This statement is incorrect. Hot showers can actually worsen itching and dry out the skin. Lukewarm showers are recommended instead.
C. "Wear loose-fitting clothing." - This statement is correct. Loose-fitting clothing can provide comfort and reduce irritation, especially in areas experiencing itching.
D. "Wear flat or low-heeled shoes." - This statement is correct. Flat or low-heeled shoes provide better support and stability during pregnancy, reducing the risk of falls.
E. "You can douche twice weekly." - This statement is incorrect. Douching is not recommended during pregnancy as it can disrupt the natural balance of vaginal flora and increase the risk of infections.
F. "Eat two large meals a day." - This statement is incorrect. Eating large meals can lead to discomfort and heartburn. It is better to eat frequent smaller meals throughout the day during pregnancy.
G. "You should avoid fried foods." - This statement is correct. Fried foods can exacerbate heartburn and should be avoided to reduce discomfort.
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