A nurse is teaching a newly licensed nurse about orthostatic hypotension. Which of the following information should the nurse include?
Orthostatic hypotension is indicated by a decrease in diastolic blood pressure of 5 mm Hg.
Orthostatic hypotension is indicated by a decrease in systolic blood pressure of 5 mm Hg.
Orthostatic hypotension increases a client's risk of a fall.
Orthostatic hypotension increases a client's risk of a pulmonary emboli.
The Correct Answer is C
A) Orthostatic hypotension is indicated by a decrease in diastolic blood pressure of 5 mm Hg:
Orthostatic hypotension is typically defined by a decrease in systolic blood pressure of 20 mm Hg or more or a decrease in diastolic blood pressure of 10 mm Hg or more within three minutes of standing up. Diastolic blood pressure alone is not the primary indicator of orthostatic hypotension.
B) Orthostatic hypotension is indicated by a decrease in systolic blood pressure of 5 mm Hg:
While a decrease in systolic blood pressure is a component of orthostatic hypotension, the criterion for diagnosing orthostatic hypotension is a decrease in systolic blood pressure of 20 mm Hg or more or a decrease in diastolic blood pressure of 10 mm Hg or more within three minutes of standing up.
C) Orthostatic hypotension increases a client's risk of a fall:
This statement is correct. Orthostatic hypotension, characterized by a sudden drop in blood pressure upon standing, can lead to dizziness and lightheadedness, increasing the risk of falls, particularly in older adults.
D) Orthostatic hypotension increases a client's risk of a pulmonary emboli:
Orthostatic hypotension is not directly associated with an increased risk of pulmonary emboli. Pulmonary embolism is a separate condition involving a blockage in the pulmonary artery or its branches, typically caused by a blood clot."
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Hypoxemia:
This is the correct answer. Atelectasis, which is the collapse or incomplete inflation of the lung, can lead to impaired gas exchange and subsequent hypoxemia. As lung volume decreases due to collapse, ventilation-perfusion (V/Q) mismatch occurs, resulting in decreased oxygenation of arterial blood. Hypoxemia is a common finding in individuals with atelectasis and may manifest as decreased oxygen saturation levels on pulse oximetry or arterial blood gas analysis.
B) Apnea:
Apnea, defined as the cessation of breathing, is not typically associated with atelectasis. While atelectasis can contribute to respiratory compromise and may result in respiratory distress, including tachypnea or increased work of breathing, it does not usually lead to complete cessation of breathing.
C) Pleural effusion:
A pleural effusion is the accumulation of fluid in the pleural space surrounding the lungs. While pleural effusion may occur concurrently with atelectasis, it is not an expected finding specifically associated with atelectasis itself. Pleural effusion may cause respiratory symptoms such as dyspnea or chest pain but is not a primary manifestation of atelectasis.
D) Dysphagia:
Dysphagia, or difficulty swallowing, is unrelated to atelectasis. While dysphagia can occur as a result of various conditions affecting the esophagus or neurological control of swallowing, it is not a typical manifestation of atelectasis. Atelectasis primarily affects the lungs and respiratory function rather than swallowing function.
Correct Answer is ["B","C","E"]
Explanation
A) Is it caused by demyelination of the nerve fibers:
Myasthenia gravis is not primarily caused by demyelination of nerve fibers. It is characterized by dysfunction at the neuromuscular junction, specifically involving the acetylcholine receptors.
B) Is it thought to be an autoimmune disease:
This is correct. Myasthenia gravis is considered an autoimmune disorder in which the body's immune system mistakenly targets and attacks its own tissues, particularly the acetylcholine receptors at the neuromuscular junction.
C) It is associated with destruction of acetylcholine receptor sites:
This is correct. In myasthenia gravis, there is a reduction in the number of functional acetylcholine receptors due to autoimmune-mediated destruction or blocking of these receptors.
D) Once symptoms present, it has a 5-year survival rate:
This statement is inaccurate. Myasthenia gravis is a chronic condition, but survival rates are not determined by the onset of symptoms. With appropriate treatment, many individuals with myasthenia gravis can manage their symptoms effectively and have a normal life expectancy.
E) It is a chronic and progressive muscular disease:
This is correct. Myasthenia gravis is a chronic neuromuscular disorder characterized by fluctuating muscle weakness and fatigue. While it is chronic, it is not necessarily progressive in all cases, as symptoms may stabilize or improve with treatment.
F) Is it best treated with antibiotics:
Antibiotics are not the primary treatment for myasthenia gravis. Treatment typically involves medications that enhance neuromuscular transmission, such as acetylcholinesterase inhibitors or immunosuppressive drugs, along with other supportive measures.
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