A nurse is teaching a newly licensed nurse about orthostatic hypotension. Which of the following information should the nurse include?
Orthostatic hypotension is indicated by a decrease in diastolic blood pressure of 5 mm Hg.
Orthostatic hypotension is indicated by a decrease in systolic blood pressure of 5 mm Hg.
Orthostatic hypotension increases a client's risk of a fall.
Orthostatic hypotension increases a client's risk of a pulmonary emboli.
The Correct Answer is C
A) Orthostatic hypotension is indicated by a decrease in diastolic blood pressure of 5 mm Hg:
Orthostatic hypotension is typically defined by a decrease in systolic blood pressure of 20 mm Hg or more or a decrease in diastolic blood pressure of 10 mm Hg or more within three minutes of standing up. Diastolic blood pressure alone is not the primary indicator of orthostatic hypotension.
B) Orthostatic hypotension is indicated by a decrease in systolic blood pressure of 5 mm Hg:
While a decrease in systolic blood pressure is a component of orthostatic hypotension, the criterion for diagnosing orthostatic hypotension is a decrease in systolic blood pressure of 20 mm Hg or more or a decrease in diastolic blood pressure of 10 mm Hg or more within three minutes of standing up.
C) Orthostatic hypotension increases a client's risk of a fall:
This statement is correct. Orthostatic hypotension, characterized by a sudden drop in blood pressure upon standing, can lead to dizziness and lightheadedness, increasing the risk of falls, particularly in older adults.
D) Orthostatic hypotension increases a client's risk of a pulmonary emboli:
Orthostatic hypotension is not directly associated with an increased risk of pulmonary emboli. Pulmonary embolism is a separate condition involving a blockage in the pulmonary artery or its branches, typically caused by a blood clot."
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Take this medication with food:
Captopril is an ACE inhibitor, known to work best on an empty stomach. Food can reduce its absorption, impacting its effectiveness. Thus, while clients can take captopril with or without food, it's generally recommended to take it on an empty stomach for optimal results.
B) Monitor for a cough:
Captopril, an ACE inhibitor, commonly induces a persistent, dry cough due to the accumulation of bradykinin. This side effect can be bothersome and may necessitate discontinuation of the medication. Therefore, patients should be vigilant for the onset of a cough and promptly report it to their healthcare provider.
C) Avoid bananas:
Although captopril can occasionally lead to hyperkalemia, advising patients to avoid bananas specifically may not be necessary. While bananas are potassium-rich, restricting them alone might not significantly impact potassium levels. However, patients should be educated on monitoring potassium intake and informed of potential dietary modifications if hyperkalemia occurs.
D) Hold medication for heart rate less than 100/min:
Captopril is not known to directly affect heart rate. This instruction may be more applicable to medications like beta-blockers, which can lower heart rate as part of their mechanism of action. Therefore, holding captopril for heart rates below 100/min may not be clinically indicated.
Correct Answer is A
Explanation
A) The sympathetic nervous system is responsible for "fight or flight":
This is the correct answer. The sympathetic nervous system is responsible for the "fight or flight" response, which prepares the body to react to perceived threats or stressors by increasing heart rate, dilating pupils, redistributing blood flow, and releasing stress hormones such as adrenaline and noradrenaline.
B) The sympathetic nervous system helps us to rest and digest:
This statement is incorrect. The parasympathetic nervous system is responsible for the "rest and digest" response, which promotes relaxation, digestion, and conservation of energy.
C) The sympathetic nervous system includes the cranial nerves:
This statement is incorrect. The sympathetic nervous system is primarily associated with the thoracolumbar region of the spinal cord and does not include the cranial nerves, which are primarily associated with the parasympathetic nervous system.
D) The sympathetic nervous system can lower blood pressure:
This statement is incorrect. The sympathetic nervous system typically increases blood pressure as part of the "fight or flight" response by increasing heart rate and constricting blood vessels to redirect blood flow to vital organs and muscles.
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