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 {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}
Explanation
A. Administer oxytocin. (This is unanticipated as the client is experiencing contractions, and oxytocin might not be needed at this point.)
D. Limit fluid intake to 3,000 mL/day. (Fluid restriction might not be necessary based on the provided notes.)
F. Place client in supine position. (The supine position is generally avoided during pregnancy due to potential compression of the vena cava.)
Correct Answer is C
Explanation
A. While additional staffing might be necessary, the nurse's priority in a mass casualty event is to assess and provide care to incoming clients.
B. Discharging specific acute care clients may not be the immediate priority in a mass casualty event.
C. Correct. In a mass casualty event, the nurse should collaborate with the emergency department to determine the medical needs and prioritize care for incoming clients.
D. Acting as a liaison between the facility and the media may not be the immediate priority during a mass casualty event.
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