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    Ati Fundamentals Proctored Exam(Applied Nursing Skills)

    A nurse is caring for a client who has postural hypotension. The nurse assists the client gradually from a lying down to standing position. The nurse should identify that which of the following findings indicates the intervention is effective?

    Explanation & Rationale

    A. A slight increase in heart rate upon standing is a normal compensatory response to postural changes. It indicates the intervention of gradually assisting the client to stand is effective in preventing significant drops in blood pressure. B. Dizziness indicates postural hypotension is still present and the intervention has not fully prevented a significant drop in cerebral perfusion. C. A minimal decrease is generally tolerated, but a drop of 20 mm Hg or more would indicate postural hypotension. Monitoring for larger drops is crucial. D. Nausea can be a symptom of insufficient cerebral perfusion or orthostatic hypotension and suggests the intervention may not be fully effective.

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