Answer to Question 1
Correct Answer: 1
Rationale 1: Orthostatic hypotension occurs when the normal vasoconstriction reflex in the legs is dormant and the client's central blood pressure drops when moving from supine to sitting or to standing.
Rationale 2: Orthostatic hypotension is a drop in blood pressure not a drop in heart rate.
Rationale 3: Paleness of the legs is not significant.
Rationale 4: The blood pressure drops, the heart rate increases, and the client may complain of dizziness or may faint upon arising.
Rationale 5: Increased respiratory rate on exertion is more related to diminished cardiac reserves, not orthostatic hypotension, as it can occur even when the client is lying flat in bed and moving.
Answer to Question 2
Correct Answer: 3
Rationale 1: The NANDA diagnosis Activity Intolerance is further individualized to the client's level of intolerance. Level 1 indicates normal activity with slightly more shortness of breath.
Rationale 2: The NANDA diagnosis Activity Intolerance is further individualized to the client's level of intolerance. Level 2 indicates ability to walk about one level city block without difficulty or to climb one flight of stairs without stopping.
Rationale 3: The NANDA diagnosis Activity Intolerance is further individualized to the client's level of intolerance. Level 3 (this client's level) indicates ability to walk no more than 50 feet on level ground without stopping and inability to climb one flight of stairs without stopping.
Rationale 4: The NANDA diagnosis Activity Intolerance is further individualized to the client's level of intolerance. Level 4 indicates dyspnea and fatigue at rest.