A nurse is caring for a client who is ambulating for the first time after surgery. Upon standing, the client reports dizziness and faintness. The client’s blood pressure is 90/50 mmHg. What is the name for this condition?
Ambulatory tachycardia
Ambulatory bradycardia
Orthostatic hypertension
Orthostatic hypotension
The Correct Answer is D
Choice A reason: Ambulatory tachycardia is not a recognized condition. Tachycardia (elevated heart rate) may occur with orthostatic changes but does not define the condition. Orthostatic hypotension, marked by a blood pressure drop (90/50 mmHg) upon standing, causes dizziness due to reduced cerebral perfusion from impaired vascular response, making this incorrect.
Choice B reason: Ambulatory bradycardia is not a standard term. Bradycardia (low heart rate) is unrelated to the symptoms of dizziness and low blood pressure (90/50 mmHg) upon standing. Orthostatic hypotension results from inadequate vasoconstriction and reduced venous return, decreasing cerebral blood flow, causing faintness, making this option incorrect.
Choice C reason: Orthostatic hypertension involves elevated blood pressure upon standing, opposite to the client’s 90/50 mmHg. Orthostatic hypotension, characterized by a drop in blood pressure, causes dizziness due to reduced cerebral perfusion from impaired baroreceptor-mediated vasoconstriction. This mismatch in symptoms and blood pressure response makes orthostatic hypertension incorrect.
Choice D reason: Orthostatic hypotension is a drop in blood pressure (e.g., 90/50 mmHg) upon standing, causing dizziness and faintness. It results from inadequate autonomic compensation, reducing venous return and cerebral perfusion. Post-surgical fluid shifts or autonomic dysfunction exacerbate this, impairing brain oxygenation, making this the correct term for the client’s condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Asking the client’s full name and date of birth ensures accurate identification, aligning with the Joint Commission’s two-identifier protocol. This method confirms the client’s identity directly, reducing medication errors and ensuring safety, as it is reliable and patient-specific, per medication administration standards.
Choice B reason: Verifying the client’s room number is unreliable, as patients may change rooms or share spaces. Room numbers are not unique identifiers and risk misidentification, leading to medication errors. This method fails to meet safety standards for patient verification, per hospital safety protocols.
Choice C reason: Checking the client’s name on the MAR is part of the process but insufficient alone, as it does not confirm the client’s identity at the bedside. Without direct patient verification, errors may occur if MARs are mismatched, making this inadequate, per medication safety guidelines.
Choice D reason: Asking a family member to verify identity is unreliable, as they may be mistaken or unavailable. Direct patient identifiers, like name and date of birth, are required to ensure accuracy, reducing errors. This method does not meet regulatory standards for patient identification, per safety protocols.
Correct Answer is D
Explanation
Choice A reason: Decreased lung compliance relates to restrictive lung diseases, not anemia. Anemia reduces oxygen-carrying capacity due to low hemoglobin, not lung elasticity. This does not affect alveolar mechanics, making it irrelevant to anemia’s impact on oxygenation, per respiratory and hematological physiology.
Choice B reason: Hypovolemia is low blood volume, not directly caused by anemia, which is low hemoglobin. Anemia affects oxygen transport, not fluid volume. While severe bleeding may cause both, hemoglobin of 7.1 g/dL indicates anemia’s primary effect is hypoxemia, per hematological assessment principles.
Choice C reason: Impaired ventilation involves airway or lung dysfunction, not anemia. Anemia reduces oxygen delivery via low hemoglobin, not gas exchange in the lungs. Ventilation remains intact, but oxygen transport is compromised, making this incorrect for anemia’s physiological impact, per respiratory physiology.
Choice D reason: Hypoxemia, low blood oxygen, results from anemia (hemoglobin 7.1 g/dL), as reduced hemoglobin decreases oxygen-carrying capacity, impairing tissue oxygenation. This causes fatigue, pallor, and tachycardia, requiring intervention like transfusion to restore oxygen delivery, per anemia’s pathophysiology and clinical management guidelines.
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