A nurse is reinforcing teaching with a newly licensed nurse about orthostatic hypotension. Which of the following information should the nurse include?

Orthostatic hypotension increases a client's risk of a fall.

Orthostatic hypotension is indicated by a decrease in systolic blood pressure of 10 mm Hg.

Orthostatic hypotension increases a client's risk of a pulmonary embolism.

Orthostatic hypotension is indicated by a decrease in diastolic blood pressure of 5 mm Hg.

Answer and Explanation

The Correct Answer is A

A. Orthostatic hypotension is characterized by a drop in blood pressure upon standing,
which can lead to dizziness or lightheadedness and increase the risk of falls, especially in older adults.
B. Orthostatic hypotension is typically indicated by a decrease in systolic blood pressure of at least 20 mm Hg or a decrease in diastolic blood pressure of at least 10 mm Hg
within 3 minutes of standing up.

C. Orthostatic hypotension does not directly increase the risk of a pulmonary embolism.

A pulmonary embolism is a separate medical condition involving a blockage in one of the pulmonary arteries in the lungs.
D. Orthostatic hypotension is typically indicated by a decrease in systolic blood pressure, not diastolic blood pressure.

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Correct Answer is C

Explanation

C. Keep the client's personal items within reach.Keeping the client's personal items within reach can provide a sense of familiarity and comfort, which may reduce anxiety or disorientation, thereby decreasing the tendency to wander.

Incorrect options:

A. "Tell the family that someone should plan to stay with the client.": While family involvement is important, this suggestion may not always be feasible. Additionally, it’s the nurse’s role to ensure the safety of the client within the facility.

B. "Place the client in a quiet room at the end of the hallway.": Isolating the client may increase confusion and feelings of disorientation.

D. "Provide bright lighting in the client's room at night.": Bright lights at night can disrupt sleep and may cause further disorientation. Dim or soft lighting or use of night lights in the room is generally more appropriate to promote restful sleep.

A. Atelectasis B. Peristalsis C. Shearing D. Deep vein thrombosis

Correct Answer is B

Explanation

A. Atelectasis refers to the collapse of lung tissue due to blockage or pressure on the airways, commonly caused by immobility but primarily affects the respiratory system.
B. Peristalsis is the natural movement of the intestines that propels food and waste products through the digestive tract. Immobility can lead to decreased peristalsis, causing constipation and other gastrointestinal issues.
C. Shearing refers to the force that causes layers of tissue to move on each other, often leading to skin breakdown and pressure ulcers. It is not directly related to
the gastrointestinal system.

D. Deep vein thrombosis (DVT) is the formation of blood clots in deep veins,

typically in the legs, due to reduced blood flow and stasis caused by immobility. It primarily affects the circulatory system, not the gastrointestinal system.

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