The nurse assesses that the 86-year-old patient is experiencing orthostatic hypotension when assessments indicate: (Select all that apply.)

a drop of 15 to 20 mm Hg from baseline when changing position.

dizziness upon rising to a standing position.

blurred vision.

syncope.

Answer and Explanation

Correct Answer : A,B,C,D

A.   A significant drop in blood pressure when standing (typically greater than 20 mm Hg systolic or 10 mm Hg diastolic) is a hallmark of orthostatic hypotension.
B.   Dizziness upon standing is a classic symptom of orthostatic hypotension due to decreased blood flow to the brain.
C.   Blurred vision can also result from decreased blood flow and is a common symptom of orthostatic hypotension.
D.   Syncope (fainting) can occur as a result of orthostatic hypotension when the brain does not receive enough oxygenated blood due to the drop in blood pressure.

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Correct Answer is C

Explanation

A. The brachial artery should be at heart level, not waist level, to ensure accurate blood pressure readings.
B. While chatting with the patient may help reduce anxiety, it is not directly related to positioning for accurate blood pressure measurement.
C. Having the patient place their feet flat on the floor ensures proper positioning and helps prevent any interference with blood pressure readings.
D. The arm should be at heart level, not at the shoulder, for accurate readings.

A. tapping. B. knocking. C. silence. D. muffling

Correct Answer is D

Explanation

A. Tapping is the first Korotkoff sound and corresponds to the systolic pressure, not the diastolic pressure.
B. Knocking does not describe any Korotkoff sound associated with the blood pressure reading.
C. Silence is typically noted after the muffling sound and indicates the cessation of Korotkoff sounds, which can be used to assess diastolic pressure in adults, but it is not used in children.
D. The muffling sound occurs before the disappearance of Korotkoff sounds and is often used to mark the diastolic pressure in both children and some adults, making it the correct answer.

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The nurse assesses that the 86-year-old patient is experiencing orthostatic hypotension when assessments indicate: (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse taking a blood pressure should:

Correct Answer is C

Explanation

A type of Korotkoff sound that indicates the diastolic pressure in children and in some adults is

Correct Answer is D

Explanation

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