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 D

Explanation

A: Low blood pressure is an objective finding that can be measured directly.

B: Shortness of breath is a subjective symptom reported by the patient.
C: Wound drainage is an objective finding that can be observed directly.

D: Feelings of fatigue are subjective symptoms reported by the patient, reflecting their personal experience rather than directly observable physical signs.

A. Bradycardia B. Hypoglycemia C. Decreased respiratory rate D. Hypertension

Correct Answer is D

Explanation

A: Bradycardia is typically not associated with acute pain; instead, pain usually triggers a sympathetic response, leading to tachycardia.
B: Hypoglycemia has no direct correlation with acute pain levels.

C: Pain tends to increase, not decrease, the respiratory rate due to stress and increased metabolic demand.
D: Acute pain can lead to elevated blood pressure as part of the body's stress response, which includes activation of the sympathetic nervous system.

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