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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"D"},"B":{"answers":"A"},"C":{"answers":"D"},"D":{"answers":"C"},"E":{"answers":"C"},"F":{"answers":"A"},"G":{"answers":"B"}}
Explanation
Rationale:
- pH 7.40: A pH of 7.40 indicates that the client's acid-base balance is normal. This supports ventilation as the client’s respiratory system is effectively managing gas exchange.
- Blood pressure 112/77 mm Hg: This stable blood pressure is a sign that the client is adequately perfused, indicating management of hypovolemia. The blood pressure is now within a normal range, suggesting effective fluid resuscitation.
- PaCO2 42 mm Hg: The PaCO2 of 42 mm Hg is within normal limits, showing that the client's ventilation is adequate and confirming support of ventilation.
- Surgical dressing dry and intact: The intact dressing is important for preventing infection, as it ensures that there is no leakage or exposure to bacteria at the surgical site.
- Temperature 98.1° F (36.7° C): A temperature of 98.1° F (36.7° C is a normal and suggests successful rewarming or maintenance of normothermia, which contributes to Prevent infection as hypothermia can impair immune function and increase infection risk.
- Capillary refill 2 seconds: Capillary refill of 2 seconds is within normal limits and indicates good circulation and tissue perfusion, which is part of managing hypovolemia.
- Pain 0 on a scale of 0 to 10: The client’s report of no pain (pain score of 0) indicates that the goal of controlling pain and anxiety is being met, ensuring that the client is comfortable and stable.
Correct Answer is A
Explanation
A. Provide a bedside commode for toileting: This intervention helps reduce the cardiac workload by minimizing the effort needed for the client to walk to the bathroom. It allows the client to conserve energy and reduce the strain on the heart.
B. Assist with ambulation in the hallway: While mobility is important, ambulating in the hallway can increase the heart’s workload, especially in a client with heart failure and pneumonia. It's best to minimize unnecessary physical exertion to prevent exacerbations.
C. Teach to sleep in a side-lying position: While side-lying can sometimes help with breathing, this position does not directly reduce the cardiac workload. The priority is ensuring the client has adequate rest and minimizing physical strain.
D. Encourage active range of motion exercises: While range of motion exercises are important for preventing complications like muscle atrophy, they may increase the cardiac workload. For a client with pneumonia and heart failure, the priority is to reduce exertion and conserve energy.
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