The nurse assesses that the 86-year-old patient is experiencing orthostatic hypotension when assessments indicate: (Select all that apply.)

a drop of 15 to 20 mm Hg from baseline when changing position.

dizziness upon rising to a standing position.

blurred vision.

syncope.

Answer and Explanation

Correct Answer : A,B,C,D

A.   A significant drop in blood pressure when standing (typically greater than 20 mm Hg systolic or 10 mm Hg diastolic) is a hallmark of orthostatic hypotension.
B.   Dizziness upon standing is a classic symptom of orthostatic hypotension due to decreased blood flow to the brain.
C.   Blurred vision can also result from decreased blood flow and is a common symptom of orthostatic hypotension.
D.   Syncope (fainting) can occur as a result of orthostatic hypotension when the brain does not receive enough oxygenated blood due to the drop in blood pressure.

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Correct Answer is C

Explanation

A. Pulse deficit refers to the difference between the apical and radial pulse, not a silence between sounds during blood pressure measurement.
B. Diastolic refers to the phase of the blood pressure cycle when the heart is at rest, not to a silent period.
C. An auscultatory gap is a period of silence between the systolic and diastolic sounds heard when taking blood pressure. It can be indicative of arterial stiffness or other vascular issues.
D. Widened pulse pressure refers to the difference between systolic and diastolic pressures, not a silence during auscultation.

A. listens to the apical pulse for 1 full minute. B. records the findings on the graphic sheet. C. takes the pulse for 30 seconds on the other wrist. D. takes the pulse for 1 full minute on the other wrist.

Correct Answer is A

Explanation

A. Listening to the apical pulse for one full minute provides a more accurate reading of the heart rate and rhythm, especially when the radial pulse is irregular.
B. Recording the findings on the graphic sheet is necessary, but it doesn’t address the irregularity of the pulse.
C. Taking the pulse on the other wrist does not provide the necessary information about the apical pulse.
D. Taking the pulse for one full minute on the other wrist is not necessary unless the pulse is absent on the first wrist.

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The nurse assesses that the 86-year-old patient is experiencing orthostatic hypotension when assessments indicate: (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

If a silence is heard between sounds when auscultating blood pressure, it is termed a(n)

Correct Answer is C

Explanation

A nurse is caring for a patient with a cardiac disease history. When measuring vital signs, the nurse finds that the radial pulse is 102 beats/min and irregular. The nurse correctly:

Correct Answer is A

Explanation

Regarding the blood pressure in children, the diastolic pressure is assessed by the auscultation of a:

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