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
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.
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