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 D
Explanation
A. Tapping is the first Korotkoff sound and corresponds to the systolic pressure, not the diastolic pressure.
B. Knocking does not describe any Korotkoff sound associated with the blood pressure reading.
C. Silence is typically noted after the muffling sound and indicates the cessation of Korotkoff sounds, which can be used to assess diastolic pressure in adults, but it is not used in children.
D. The muffling sound occurs before the disappearance of Korotkoff sounds and is often used to mark the diastolic pressure in both children and some adults, making it the correct answer.
Correct Answer is B
Explanation
A. The bell is used to detect low-pitched sounds, but abnormal heart sounds are often high-pitched, requiring the diaphragm.
B. The diaphragm of the stethoscope is best for detecting high-pitched heart sounds, such as murmurs or abnormal rhythms.
C. The diaphragm on top of the gown would create interference and prevent proper auscultation of heart sounds.
D. The bell is used for lower-pitched sounds and is not the best choice for auscultating abnormal heart sounds.
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