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) By blocking the effects of histamine in the body:
Antihistamines are pharmacological agents that work by antagonizing the effects of histamine, a chemical mediator released by mast cells and basophils in response to allergens or other triggers. Histamine contributes to various allergic symptoms such as itching, sneezing, nasal congestion, and watery eyes. Antihistamines exert their effects by competitively binding to histamine receptors (specifically H1 receptors) on target cells, thereby preventing histamine from binding and exerting its physiological effects. By blocking histamine receptors, antihistamines inhibit the action of histamine, leading to the alleviation of allergy symptoms.
B) By reducing inflammation in the body:
While some medications, such as corticosteroids, exert anti-inflammatory effects by suppressing the immune response and inhibiting the production of inflammatory mediators, antihistamines primarily target histamine receptors and do not directly reduce inflammation. Although histamine release can contribute to inflammation, antihistamines mitigate allergic symptoms primarily by blocking the action of histamine rather than by directly reducing inflammation.
C) By increasing the production of histamine in the body:
This statement is inaccurate. Antihistamines do not increase the production of histamine; instead, they counteract the effects of histamine by blocking its activity at receptor sites. The primary mechanism of action of antihistamines involves blocking histamine receptors to prevent histamine from exerting its physiological effects.
D) By stimulating the immune system:
Antihistamines do not stimulate the immune system. Instead, they act as antagonists to histamine receptors, thereby inhibiting histamine-induced responses. While histamine is involved in immune responses and allergic reactions, antihistamines do not directly modulate immune function or stimulate immune activity. Their primary role is to alleviate allergy symptoms by blocking the effects of histamine."
Correct Answer is B
Explanation
A) Weight and caloric intake:
While weight and caloric intake are important aspects of overall health assessment, they are not directly related to the administration of beta-adrenergic blocking agents. These medications primarily affect cardiovascular function, so assessing pulse and blood pressure is more pertinent.
B) Pulse and blood pressure:
This is the correct answer. Before administering beta-adrenergic blocking agents, it is essential to assess the client's pulse rate and blood pressure. Beta blockers work by blocking the effects of adrenaline, leading to a decrease in heart rate and blood pressure. Monitoring these vital signs helps determine the appropriateness of administering the medication and allows for adjustments based on the client's current cardiovascular status.
C) Serum sodium level:
Assessing serum sodium level is not typically necessary before administering beta-adrenergic blocking agents. While electrolyte imbalances can occur as a result of certain medications or health conditions, beta blockers do not directly affect serum sodium levels.
D) Serum albumin level:
Assessing serum albumin level is not specifically indicated before administering beta-adrenergic blocking agents. Serum albumin levels may be assessed in clients with certain conditions such as liver or kidney disease, but it is not a routine assessment before administering beta blockers.
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