A nurse is assessing a client who reports feeling dizzy upon standing. The client's blood pressure is 100/60 mm Hg while seated and drops to 85/55 mm Hg when standing. What does this finding most likely indicate?
Hypertension.
Normal variation.
Orthostatic hypotension.
Dehydration.
The Correct Answer is C
A. Hypertension involves elevated blood pressure, which is not consistent with this client’s readings.
B. A normal variation does not typically involve a significant drop in blood pressure accompanied by dizziness upon standing.
C. Orthostatic hypotension is indicated by a drop in systolic pressure of ≥20 mm Hg or diastolic pressure of ≥10 mm Hg within 2–5 minutes of standing, often accompanied by dizziness, lightheadedness, or fainting. This client’s blood pressure drops from 100/60 mm Hg to 85/55 mm Hg, fitting the criteria.
D. Dehydration can contribute to orthostatic hypotension but is a broader condition; the immediate finding is consistent with orthostatic hypotension, which may have multiple underlying causes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Bioenergetic therapies involve the manipulation of energy fields in the body, such as Reiki or therapeutic touch, not nutritional supplements.
B. Manual therapies involve physical manipulation of muscles and joints, such as massage or chiropractic care.
C. Mind-body therapies focus on the interaction between the brain and body to improve health, including meditation, yoga, or hypnosis.
D. Biological therapies include interventions using substances found in nature to promote health, such as nutritional supplements, vitamins, herbs, and probiotics. These therapies support the body’s biological processes and complement conventional treatments.
Correct Answer is A
Explanation
A. Encouraging the client to take slow, deep breaths addresses not only the physical aspect of pain but also the emotional and psychological components, reflecting a holistic nursing approach that considers the whole person—mind, body, and spirit.
B. Checking the client’s oxygen saturation level is a standard physiological assessment and addresses only the physical aspect of health, not the holistic needs of the client.
C. Obtaining blood work focuses on diagnostic data for physical health and does not incorporate emotional, psychological, or spiritual aspects of care.
D. Requesting a prescription for an analgesic addresses pain management from a biomedical perspective but does not include holistic interventions that support overall well-being.
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