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 D

Explanation

Rationale
A. Pumping the cuff until no sound is heard may cause inaccurate readings and is not a proper technique.
B. Stopping midway can result in missing sounds or causing an inaccurate measurement.

C. The bell of the stethoscope should be used for low-pitched sounds, but the key is to continue listening to identify the full Korotkoff sound range, especially in the presence of an auscultatory gap.
D. It is important to continue listening until the cuff is deflated to ensure the accurate measurement of both systolic and diastolic pressures, particularly in patients with an auscultatory gap.

A. push the soles of the feet against the nurse's hands. B. wiggle the toes of both feet at the same time. C. pull both feet up at the same time to stretch the Achilles tendons. D. stand up independently

Correct Answer is A

Explanation

A. Pushing the soles of the feet against the nurse's hands is a standard test to assess the strength of the lower extremities. It provides a clear indication of muscular strength and motor function.
B. Wiggling toes helps assess for sensation but does not evaluate overall strength or motor function in the lower extremities.
C. Pulling both feet up to stretch the Achilles tendons is not an appropriate method for assessing lower extremity strength.
D. Standing independently does not evaluate strength comprehensively and is more related to balance and coordination.

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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

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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