A nurse is assessing a client for orthostatic hypotension. Which actions should the nurse take during the assessment? (Select all that apply)

Choice A reason: The procedure for detecting orthostatic (postural) hypotension requires sequential blood pressure and pulse measurements in three distinct positions: supine, sitting, and standing. This allow the nurse to observe how the cardiovascular system compensates for the gravitational shifts in blood volume during position changes. Choice B reason: Orthostatic hypotension is clinically defined as a decrease in systolic blood pressure of at least 20 mmHg or a decrease in diastolic blood pressure of at least 10 mmHg within three minutes of standing. Recording these specific drops is essential for a definitive diagnosis of the condition. Choice C reason: Providing water before the test could artificially inflate the blood volume and mask orthostatic hypotension. The goal of the test is to evaluate the body's baseline compensatory mechanisms. Adding fluids would interfere with the accuracy of the assessment by temporarily correcting potential dehydration-induced hypotension. Choice D reason: The client must remain still during each measurement to ensure an accurate blood pressure reading. Walking or physical activity during the test would stimulate the sympathetic nervous system and muscular pump, which could falsely elevate the blood pressure and invalidate the results of the orthostatic assessment. Choice E reason: A brief rest period of 1 to 2 minutes (sometimes up to 3 minutes) between each position change is necessary to allow the blood to redistribute and the baroreceptor reflex to respond. Taking the measurement too quickly would not give the body enough time to show a true postural reaction.