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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Checking for normal, coordinated eye movement is key when assessing extraocular movements, which should be smooth and symmetric.
B. Pupillary dilation occurs under specific circumstances, such as low light, not necessarily when focusing on an object.
C. Blinking is a normal reflex but not a primary indicator when assessing extraocular movements.
D. Pupillary constriction is a separate function of the pupillary light reflex and not directly associated with extraocular movements.
Correct Answer is D
Explanation
A. Hyperthermia refers to an abnormally high body temperature due to external factors or failure to regulate body heat, not necessarily a fever coming down.
B. Pyrexia is another term for fever and occurs when the body temperature is elevated due to an infection or other causes.
C. Hypothermia refers to dangerously low body temperature, which is not related to a fever resolving.
D. Defervescence refers to the process of a fever breaking, and the body temperature returning to normal as the fever resolves.
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