A nurse is taking a blood pressure measurement to assess for orthostatic hypotension in a client. Which signs and symptoms will the nurse assess related to this condition? (Select all that apply.)
Client reports feeling dizzy when sitting up from a supine position.
Client reports feeling palpitations when rising from a supine to a standing position.
Erythema is present on the bilateral lower extremities
The client has a temperature of 100.4 F
The client states, “I feel lightheaded when sitting up.”
Correct Answer : A,D,E
A. Client reports feeling dizzy when sitting up from a supine position.
Dizziness or lightheadedness when moving from a lying down to a sitting or standing position can be indicative of orthostatic hypotension.
B. Client reports feeling palpitations when rising from a supine to a standing position.
Palpitations (feeling of rapid or irregular heartbeat) can be associated with orthostatic changes and may indicate the heart's compensatory response to low blood pressure.
C. Erythema is present on the bilateral lower extremities.
Erythema (redness of the skin) is not typically associated with orthostatic hypotension. This symptom is more likely related to skin conditions or other causes.
D. The client has a temperature of 100.4 F.
Fever (elevated body temperature) is not a direct symptom of orthostatic hypotension. Orthostatic hypotension is primarily related to changes in blood pressure upon assuming an upright position.
E. The client states, “I feel lightheaded when sitting up.”
Lightheadedness upon sitting up or standing is a common symptom of orthostatic hypotension.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The client attempted to climb over the side rails and fell:
This statement includes an interpretation of the client's actions. It's important to focus on factual information without making assumptions about the client's intentions or actions.
B. The client was restless and trying to get out of bed all evening:
Describing the client as restless and trying to get out of bed is a subjective interpretation of the client's behavior. Factual and objective observations are preferred when documenting incidents.
C. The presence of a bed alarm could have prevented the client from falling:
This statement includes an interpretation and a suggestion for prevention. While prevention strategies are important to consider, an incident report should primarily focus on describing what actually occurred rather than suggesting what could have prevented it.
D. The client was lying on the floor next to his bed:
This statement provides a clear and objective description of the situation without making assumptions or interpretations. It is important to document the actual events and the client's current condition.
Correct Answer is ["0.7"]
Explanation
To calculate the amount of hydroxyzine (Vistaril) to administer, use the formula:
D (desired dose) / H (have dose) x Q (quantity) = X (amount to give)
In this case, D = 35 mg, H = 50 mg/mL, and Q = 1 mL. Plug in the values and solve for X:
35 mg / 50 mg/mL x 1 mL = 0.7 mL
Therefore, the amount of hydroxyzine (Vistaril) to administer is 0.7 mL.
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