A nurse is assessing a client for possible orthostatic hypotension. Which finding will help confirm orthostatic hypotension?

Blood pressure sitting 126/64; blood pressure standing 120/58

Blood pressure sitting 140/60; blood pressure standing 138/58

Blood pressure sitting 130/60; blood pressure standing 100/60

Blood pressure sitting 120/64; blood pressure standing 120/64

Answer and Explanation

The Correct Answer is C

A. Blood pressure sitting 126/64; blood pressure standing 120/58: The systolic drop is 6 mm Hg and diastolic drop 6 mm Hg -these changes are small and do not meet orthostatic criteria.

B. Blood pressure sitting 140/60; blood pressure standing 138/58: The systolic drop is 2 mm Hg and diastolic drop 2 mm Hg -these minimal changes do not indicate orthostatic hypotension.

C. Blood pressure sitting 130/60; blood pressure standing 100/60: The systolic drop is 30 mm Hg (≥20 mm Hg), which meets the standard definition of orthostatic hypotension and supports that diagnosis.

D. Blood pressure sitting 120/64; blood pressure standing 120/64: No change in blood pressure readings is seen, which does not indicate orthostatic hypotension.

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Correct Answer is D

Explanation

A. A 75-year-old client who can perform active ROM exercises independently and will be discharged today: Independence with ROM and imminent discharge indicate relative stability and lower immediate risk compared with other options.

B. A 24-year-old client who is grieving after receiving a cancer diagnosis: Emotional support and assessment are important, but grief alone is not immediately life- or safety-threatening compared with clients at higher risk for physical deterioration.

C. A 65-year-old client who has been admitted from a long-term care facility and has several wounds with slough: Multiple sloughing wounds increase risk for infection and require prompt wound assessment and treatment; this client has significant care needs.

D. A 55-year-old client who is newly admitted and is refusing to be turned every 2 hours: This refusal places the client at immediate risk for pressure injury and other immobility complications; because the client is newly admitted and actively refusing a basic safety measure, assessing the reason for refusal and initiating interventions to prevent harm make this the priority for immediate nursing action.

A. Risk for impaired nutrition B. Risk for falls C. Risk for aspiration D. Risk for skin breakdown

Correct Answer is D

Explanation

A. Risk for impaired nutrition: The Braden Scale is not designed to evaluate nutritional risk specifically, though nutrition affects skin integrity.

B. Risk for falls: The Braden Scale does not assess fall risk; separate tools exist for fall-risk screening.

C. Risk for aspiration: Aspiration risk is not what the Braden Scale measures.

D. Risk for skin breakdown: The Braden Scale evaluates sensory perception, moisture, activity, mobility, nutrition, and friction/shear to determine risk for pressure injury/skin breakdown.

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A nurse is assessing a client for possible orthostatic hypotension. Which finding will help confirm orthostatic hypotension?

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Naxlex Comprehensive Predictor Exams

After obtaining handoff communication from the previous shift's nurse, the nurse knows that which client is the PRIORITY?

Correct Answer is D

Explanation

If a nurse is using the Braden scale for a client, the nurse is utilizing the scale to determine:

Correct Answer is D

Explanation

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