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) Decreased bowel sounds:
While diarrhea can lead to changes in bowel function, such as increased frequency and urgency, it typically does not cause decreased bowel sounds. In fact, hyperactive bowel sounds may be present in some cases of diarrhea due to increased gastrointestinal motility and peristalsis as the body attempts to expel excess stool.
B) Dehydration:
This is the correct answer. Diarrhea can result in fluid and electrolyte losses, leading to dehydration if not adequately managed. Common symptoms of dehydration include increased thirst, dry mucous membranes, decreased urine output, dark urine, fatigue, weakness, and dizziness. In severe cases, dehydration can lead to hypovolemic shock, a life-threatening condition requiring immediate medical attention.
C) Rigid abdomen:
While abdominal discomfort and cramping are common symptoms of diarrhea, a rigid abdomen is not typically associated with uncomplicated cases of diarrhea. However, severe abdominal pain, distention, and rigidity may indicate underlying complications such as bowel obstruction or peritonitis, which require urgent medical evaluation.
D) Hypothermia:
Hypothermia, or abnormally low body temperature, is not a typical finding in clients with diarrhea. In fact, diarrhea is more commonly associated with fluid and electrolyte imbalances that can lead to hyperthermia (elevated body temperature) due to dehydration and inflammatory responses. However, hypothermia may occur in severe cases of dehydration or sepsis, but it is not a direct consequence of diarrhea itself.
Correct Answer is C
Explanation
A) "I should limit my fluid intake while taking this medication":
This statement is incorrect. Furosemide is a loop diuretic that increases urine production to reduce fluid overload in conditions like heart failure or edema. It is essential for clients taking furosemide to maintain adequate hydration to prevent dehydration. Therefore, the client should not limit their fluid intake while taking this medication.
B) "My blood pressure will increase while I am taking this medication":
This statement is incorrect. Furosemide is primarily used to reduce blood pressure by promoting diuresis and reducing fluid volume. Therefore, it is unlikely that blood pressure would increase while taking this medication.
C) "I should take this medication in the morning rather than at night":
This is the correct answer. Furosemide is usually taken in the morning to prevent nocturia (excessive urination at night), as it can increase urinary frequency. Taking it earlier in the day allows for better fluid balance during waking hours and reduces the need to wake up frequently during the night to urinate.
D) "I should eat a diet low in potassium while taking this medication":
This statement is incorrect. Furosemide can cause potassium depletion as a side effect, so clients may be advised to consume potassium-rich foods or supplements unless contraindicated due to other medical conditions. However, it is not necessary to eat a diet low in potassium while taking furosemide unless specifically instructed by a healthcare provider.
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