A nurse is assessing a patient with activity intolerance for possible orthostatic hypotension. Which finding will help confirm orthostatic hypotension?
Blood pressure sitting 140/60; blood pressure 130/60 standing
Blood pressure sitting 130/60; blood pressure 110/60 standing
Blood pressure sitting 126/64; blood pressure 120/58 standing
Blood pressure sitting 130/64; blood pressure 140/70 standing
The Correct Answer is B
A: A drop in systolic blood pressure of 10 mm Hg (from 140 to 130) does not meet the criteria for orthostatic hypotension, which requires a drop of at least 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure within three minutes of standing.
B: This finding shows a drop in systolic blood pressure from 130 to 110 mm Hg, which is a 20 mm Hg decrease. This meets the criteria for orthostatic hypotension, indicating that the patient may have this condition.
C: A drop in systolic blood pressure of 6 mm Hg (from 126 to 120) does not meet the criteria for orthostatic hypotension. The decrease is not significant enough to confirm the condition.
D: An increase in blood pressure (from 130/64 to 140/70) does not indicate orthostatic hypotension. This finding suggests that the patient’s blood pressure increases upon standing, which is not consistent with orthostatic hypotension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A: 20 mg is incorrect and represents a significant overdose. It is not an appropriate transcription for two tenths of a milligram.
B: 0.20 mg is not the best practice because it can be misread as 20 mg if the decimal point is missed. Leading zeros should be used without trailing zeros to prevent errors.
C: 0.2 mg is the correct transcription. It clearly represents two tenths of a milligram and minimizes the risk of misinterpretation.
D: 2.0 mg is incorrect and represents a tenfold overdose. It is not an appropriate transcription for two tenths of a milligram.
Correct Answer is D
Explanation
A: Degenerative joint changes can affect mobility and overall health but do not directly contribute to aspiration pneumonia.
B: Decreased gastric secretions can affect digestion but are not a primary factor in the development of aspiration pneumonia.
C: A decreased sense of smell can affect appetite and food intake but does not directly lead to aspiration pneumonia.
D: A diminished cough reflex is a significant age-related change that can contribute to the development of aspiration pneumonia. The cough reflex helps clear the airway of food, liquid, and other foreign materials. When this reflex is diminished, the risk of aspiration and subsequent pneumonia increases.
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