Author Question: The nurse has documented that the client has orthostatic hypotension. Which assessment findings ... (Read 48 times)

saliriagwu · **on:** Jul 23, 2018

The nurse has documented that the client has orthostatic hypotension. Which assessment findings would support this assessment? (Select all that apply.)

1. Decrease in blood pressure when moving from supine to standing
2. Decrease in heart rate when moving from supine to sitting
3. Pale color in the legs when lying in bed
4. Complaints of dizziness when first sitting up
5. Increased respiratory rate on exertion

Question 2

The client's chief complaint is, I just can't get around like I used to. I have to stop halfway up the stairs to the bedroom, and just walking to the bathroom makes me so tired. Which nursing diagnosis is most likely appropriate for this clien

Activity Intolerance:
1. Level 1
2. Level 2
3. Level 3
4. Level 4

wshriver · **Reply #1 on:** Jul 23, 2018

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.