A client's most recent vital signs include heart rate 80 beats/minute and blood pressure 119/70 mm Hg. When the client reports dizziness after rising quickly, which finding should the nurse expect on reassessment?
Heart rate 100 beats/minute.
Blood pressure 125/65 mm Hg.
Heart rate 70 beats/minute.
Blood pressure 115/70 mm Hg.
The Correct Answer is A
A. Heart rate 100 beats/minute: A compensatory increase in heart rate (tachycardia) is expected in orthostatic hypotension. It helps maintain cerebral perfusion when blood pools in the lower extremities after standing quickly.
B. Blood pressure 125/65 mm Hg: This BP shows a slight systolic increase, which is not typical after orthostatic stress. A decrease in BP, not an increase, would be expected if symptoms like dizziness are present.
C. Heart rate 70 beats/minute: A decreased heart rate is not physiologically expected when someone experiences postural hypotension. Bradycardia would worsen cerebral perfusion and is inconsistent with dizziness.
D. Blood pressure 115/70 mm Hg: This change is too minor to explain dizziness. In orthostatic hypotension, we usually expect a drop of ≥20 mm Hg systolic or ≥10 mm Hg diastolic after position change.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Instruct the client to take an antiemetic before every meal to prevent excessive vomiting:While antiemetics can be helpful, this action may not address the underlying issue of food smells causing nausea. It is important to address the client’s sensory triggers.
B. Encourage family members to cook meals outdoors and bring the cooked food inside:
This can help reduce the trigger for nausea caused by the smell of cooking food. Cooking outdoors minimizes exposure to food smells, which could alleviate the client’s discomfort.
C. Assess the client's mucous membranes and report the findings to the healthcare provider: Assessing the mucous membranes is important in general care, especially for clients with cancer, but it is not directly related to the reported issue of nausea triggered by food smells.
D. Advise the client to replace cooked foods with a variety of different nutritional supplements: While nutritional supplements can be useful if the client is unable to tolerate solid foods, this advice doesn't address the root cause of the nausea related to food smells.
Correct Answer is D
Explanation
A. Ask if the client is experiencing any change in bowel habits: Changes in bowel habits are not directly related to the confusion or memory loss seen in pernicious anemia. The concern here is primarily with vitamin B12 deficiency.
B. Determine if the client is taking iron and folic acid supplements: While iron and folic acid are important, they don't directly address the memory loss and confusion related to B12 deficiency. The immediate focus should be on the effects of the B12 treatment.
C. Encourage the husband to bring the client to the clinic for a complete blood count: A CBC can help monitor anemia, but it doesn't address the memory issues. The nurse should first explain the symptoms related to B12 deficiency.
D. Explain that memory loss and confusion are common with vitamin B12 deficiency:
Memory loss and confusion are known symptoms of vitamin B12 deficiency. These symptoms may take time to improve with treatment, and educating the husband helps alleviate concerns.
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