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 D
Explanation
A. Incorrect. Premature atrial complexes do not typically affect the P-R interval. They are characterized by an early P-wave followed by a QRS complex.
B. Incorrect. Complete heart block is characterized by a dissociation between the P-waves and QRS complexes, resulting in no relationship between atrial and ventricular activity.
C. Incorrect. Atrial fibrillation is characterized by chaotic and irregular atrial activity without distinct P-waves, making the P-R interval irrelevant.
D. Correct. In first-degree atrioventricular block, the P-R interval is prolonged beyond the normal range of 0.12-0.20 seconds. A constant P-R interval of 0.35 seconds indicates a first- degree atrioventricular block.
Correct Answer is B
Explanation
A. While staff training is important, it may not address the immediate concern of identifying the cause of the infections.
B. Correct. Identifying the possible factors contributing to the infections is the first step in addressing the issue and preventing further infections.
C. Meeting with providers can be beneficial, but identifying the cause should come first before discussing measures.
D. Revising the policy for catheter care can be considered once the contributing factors are identified.
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