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: Dyspnea, or difficulty breathing, can occur in various conditions but is not a primary manifestation of hypovolemia. Hypovolemia primarily affects the cardiovascular system due to reduced blood volume.
B: Increased blood pressure is not a typical manifestation of hypovolemia. In fact, hypovolemia usually leads to decreased blood pressure due to the reduced volume of circulating blood.
C: A weak pulse is a common manifestation of hypovolemia. The reduced blood volume leads to decreased cardiac output, resulting in a weak and thready pulse.
D: Decreased heart rate is not typical in hypovolemia. The body usually compensates for low blood volume by increasing the heart rate (tachycardia) to maintain adequate circulation.
Correct Answer is D
Explanation
A: Hypotension is not an early sign of hypoxemia. It can occur in severe cases but is not typically an initial indicator.
B: Nausea is not a common sign of hypoxemia. It may occur due to other factors but is not directly related to low oxygen levels.
C: Dysphagia, or difficulty swallowing, is not a sign of hypoxemia. It is related to swallowing disorders rather than oxygen levels.
D: Confusion is an early sign of hypoxemia. Low oxygen levels can affect brain function, leading to confusion and other cognitive changes.
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