54. As a nurse is assisting a client out of bed, which objective sign should indicate to the RN that the client is experiencing hypotension?
54. As a nurse is assisting a client out of bed, which objective sign should indicate to the RN that the client is experiencing hypotension?
. Pupil response is sluggish to light.
. Orientation level changes.
. Pulse rate increases 20 beats per minute.
. Increased muscle rigidity in legs.
Test-Taking Tip
Think how the body would respond to maintain adequate blood flow.
Content Area: Adult Health, Cardiovascular; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Pathophysiology
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Answer 1 is incorrect because pupillary changes related to cerebral hypoxia and increased ICP are very late signs. Answer 2 is incorrect because the body would try to compensate for the drop in BP before a change in LOC. Answer 3 is correct because an increase in pulse would be an attempt by the body to increase the BP. Answer 4 is incorrect because the client would be more likely to become weak (i.e., flaccid extremities) if hypotension occurs.