A nurse is assessing a patient with activity intolerance for ...

[nautica902]

A nurse is assessing a patient with activity intolerance for possible orthostatic hypotension. Which finding will help confirm orthostatic hypotension?
 
  a. Blood pressure sitting 120/64; blood pressure 140/70 standing
  b. Blood pressure sitting 126/64; blood pressure 120/58 standing
  c. Blood pressure sitting 130/60; blood pressure 110/60 standing
  d. Blood pressure sitting 140/60; blood pressure 130/54 standing

Question 2

A patient is admitted with a stroke. The outcome of this disorder is uncertain, but the patient is unable to move the right arm and leg. The nurse starts passive range-of-motion (ROM) exercises. Which finding indicates successful goal achievement?
 
  a. Heart rate decreased.
  b. Contractures developed.
  c. Muscle strength improved.
  d. Joint mobility maintained.

[rekilledagain]

Answer to Question 1

ANS: C
Orthostatic hypotension results in a drop of 20 mm Hg systolic or more in blood pressure when rising from sitting position (110/60). 120 to 140 means the blood pressure increased rather than dropped. 126 to 120 is only a six points' difference. 140 to 130 is only a 10 points' difference.

Answer to Question 2

ANS: D
When patients cannot participate in active ROM, maintain joint mobility and prevent contractures by implementing passive ROM into the plan of care. Exercise and active ROM can improve muscle strength. ROM is not performed for the heart but for the joints.

[nautica902]

TYSM

[T4T]

Excellent