The patient has a history of orthostatic hypotension. What is the priority action of the nurse?
Always take the patient's blood pressure manually using a sphygmomanometer.
Monitor the patient's neurological status carefully for symptoms of a stroke.
Assist the patient to sit and stand slowly when getting out of bed.
Check the patient's blood pressure on a lower extremity using a thigh-sized cuff.
The Correct Answer is C
A. Always take the patient's blood pressure manually using a sphygmomanometer. While manual BP measurements can be more accurate, they are not the priority intervention for orthostatic hypotension, which primarily involves position changes and fall prevention.
B. Monitor the patient's neurological status carefully for symptoms of a stroke. Orthostatic hypotension can cause dizziness or fainting, but it is not a direct cause of stroke. Neurological assessment is important if symptoms arise but is not the primary intervention.
C. Assist the patient to sit and stand slowly when getting out of bed. Orthostatic hypotension causes a sudden drop in blood pressure upon standing, increasing the risk of falls and syncope. The priority action is to help the patient transition slowly from lying to sitting and standing to allow the body to adjust.
D. Check the patient's blood pressure on a lower extremity using a thigh-sized cuff. Lower extremity BP measurements are not standard for managing orthostatic hypotension. Blood pressure should be checked in both lying, sitting, and standing positions to monitor for significant drops.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["39.2"]
Explanation
Calculation:
The formula to convert Fahrenheit (°F) to Celsius (°C) is:
°C = (°F - 32) × 5/9
= (102.5 - 32) × 5/9
= (70.5) × 5/9
= 39.1666...
Rounding to the nearest tenth: 39.2 °C.
Therefore, 102.5 °F is equal to 39.2 °C.
Correct Answer is A
Explanation
A. Falsely low. Using an adult-sized cuff on a child results in an overestimation of the cuff size, causing the cuff to not inflate properly and distribute less pressure, leading to a falsely low blood pressure reading.
B. Indistinct. The reading may be inaccurate, but it will still produce a numerical value rather than being completely indistinct.
C. Accurate. Accuracy depends on using a cuff size appropriate for the child's arm circumference. An adult cuff on a child is too large, leading to an incorrect reading.
D. Falsely high. A too-small cuff would produce a falsely high reading, but an oversized cuff produces a falsely low blood pressure.
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