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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Comatose:
Coma refers to a state of deep unconsciousness where the individual is unresponsive to stimuli, including pain or external stimulation. In the scenario described, the patient is not comatose because they can be awakened by gentle shaking and calling their name.
B. Awake and alert:
This term describes a state of full alertness and responsiveness to the environment. The patient in the scenario is not fully awake and alert since they appear drowsy most of the time and require external stimuli to be awakened.
C. Lethargic:
Lethargy is characterized by drowsiness, reduced alertness, and a sluggish response to stimuli. In the scenario, the patient is described as drowsy most of the time but can be awakened by gentle shaking and calling their name. This aligns with the characteristics of lethargy.
D. Stuporous:
Stupor is a state of reduced responsiveness where the individual can be aroused only by vigorous or painful stimuli. The patient in the scenario does not fit the criteria for stupor as they can be awakened by gentle shaking and calling their name.
Correct Answer is B
Explanation
A. Change the plan of care to provide different pain relief interventions:
While changing the plan of care may be necessary, it should be based on a thorough reassessment. Simply changing the plan without understanding the reasons for inadequate pain relief may not lead to effective outcomes.
B. Reassess the client to determine the reasons for inadequate pain relief.
Reassessment is a crucial step in the nursing process, especially when the desired outcomes are not achieved. By reassessing the client, the nurse can identify any factors contributing to the inadequate pain relief. This might include reevaluating the effectiveness of the current pain relief interventions, ensuring proper administration of medications, considering changes in the client's condition, or exploring any new factors affecting pain.
C. Teach the client about the plan of care for managing his pain:
Teaching is an important aspect, but in this case, reassessment takes precedence. Once the reasons for inadequate pain relief are determined, teaching can be tailored to address specific needs.
D. Wait to see whether the pain lessens during the next 24 hours:
If the pain is not adequately controlled, waiting for another 24 hours without action may prolong the client's discomfort and delay appropriate interventions. Reassessment and prompt adjustments to the plan of care are crucial for effective pain management.
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