A nurse is collecting data on a client to check for orthostatic hypotension. Which of the following actions should the nurse take first?

Check the blood pressure with the client in a supine position.

Place the client in a sitting position.

Determine the client's blood pressure 1 min after each position change.

Assist the client into a standing position.

Answer and Explanation

The Correct Answer is A

A: To accurately assess for orthostatic hypotension, the initial blood pressure should be measured while the client is supine. This establishes a baseline for comparing subsequent measurements.
B: Placing the client in a sitting position is a subsequent step in the sequence to monitor changes but is not the first action.
C: Determining the client's blood pressure changes after each position is essential but follows the initial supine measurement.
D: Assisting the client into a standing position is also part of the assessment process for orthostatic hypotension but should occur after recording the supine and sitting blood pressures.

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Correct Answer is B

Explanation

A: Subjective information refers to what the patient experiences and reports, not what is sensed by the observer.
B: Objective signs are those that can be observed and measured by someone other than the patient, such as visual inspections, palpations, and auditory cues.
C: Reported by the patient would be subjective data, opposite of what is sensed and recorded by healthcare providers.
D: Hidden signs would imply they are not readily observable, which contradicts the use of senses to identify them.

A. The patient's spouse reports experiencing marital issues. B. The patient reports a history of chest pain. C. The patient complains of chronic constipation. D. The patient verbalizes anxiety about hospitalization.

Correct Answer is A

Explanation

A. The patient's spouse reporting experiencing marital issues is a perfect example of secondary information as it comes from someone other than the patient and might affect the patient's care or emotional well-being indirectly.
B. The patient reports a history of chest pain, is an example of primary information. This is because the patient directly reports the symptoms of their health condition.
C. The patient complaining of chronic constipation is an example of primary information. This is because the patient is directly reporting their own health condition.

D. The patient verbalizes anxiety about hospitalization is also primary information, directly provided by the patient concerning their feelings about the current care environment.

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A nurse is collecting data on a client to check for orthostatic hypotension. Which of the following actions should the nurse take first?

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