# Situation: A 64-year-old man is on the rehabilitation ward 10 days after an ischemic stroke in the left cerebral hemisphere. He has right-sided weakness and aphasia. He takes aspirin 80 mg and atorvastatin 40 mg once daily. Walking practice with him is planned to start today. Before the session, the nurse notes the findings below. Which finding should the nurse report so that walking practice is postponed?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630518  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 64-year-old man is on the rehabilitation ward 10 days after an ischemic stroke in the left cerebral hemisphere. He has right-sided weakness and aphasia. He takes aspirin 80 mg and atorvastatin 40 mg once daily.

Walking practice with him is planned to start today. Before the session, the nurse notes the findings below. Which finding should the nurse report so that walking practice is postponed?

## 보기

1. Resting heart rate of 88 beats per minute and regular
2. Blood pressure 136/82 mmHg lying, 110/70 mmHg standing **✔ 정답**
3. Pauses to search for words when he answers questions
4. Right leg strength graded 3 out of 5 on manual testing

**정답: 2**

## 해설

Before gait training after hemiplegia, sitting and standing balance and orthostatic blood pressure are checked. A fall of 26 mmHg systolic on standing is orthostatic hypotension, which makes him likely to faint and fall during walking practice, so it is reported first. Strength of 3 out of 5 allows supported walking, and the other findings do not affect safe standing.

## 심화 해설

Orthostatic hypotension makes walking unsafe today
Before gait training in a client with hemiplegia, the nurse checks sitting and standing balance and orthostatic blood pressure. His blood pressure is 136/82 mmHg lying and 110/70 mmHg standing, a fall of 26 mmHg systolic. A drop of 20 mmHg or more systolic, or 10 mmHg or more diastolic, on standing indicates orthostatic hypotension. A 26 mmHg systolic fall on standing puts him at risk of fainting and falling, so it is reported and walking practice is postponed.

Why orthostatic hypotension matters after stroke
After a stroke and days of reduced activity, the body's reflex responses to standing are weakened. When he stands, blood pools in the legs, cerebral blood flow can fall, and he may become dizzy, faint, or fall. A fall in a client with right-sided weakness who is taking aspirin could cause injury, including head injury with bleeding. Reduced cerebral perfusion could also be harmful to the recovering brain. The nurse reports the finding so the cause can be evaluated, for example dehydration or medication effects, and walking is resumed when standing blood pressure is stable.

| Finding | Significance | Postpone walking? |
| --- | --- | --- |
| Resting heart rate 88, regular | Within normal limits | No |
| Blood pressure 136/82 lying, 110/70 standing | Orthostatic hypotension | Yes |
| Word-finding pauses | Expressive aphasia; does not affect gait safety | No |
| Right leg strength 3/5 | Moves against gravity; supported gait possible | No |

Why the other findings do not stop the session
A regular resting heart rate of 88 beats/min is normal. Word-finding pauses reflect his expressive aphasia, which affects language, not balance or safety while walking. Right leg strength of 3/5 means he can move the leg against gravity, which allows supported gait training with a gait belt and assistance. Watch out! Weakness may look like the most important finding in a walking question, but the immediate safety risk here is the drop in blood pressure.

Exam takeaway
Before mobilizing a client, check orthostatic vital signs, balance, and readiness, and protect the client with a gait belt and assistance. Key point! A systolic drop of 20 mmHg or more on standing is orthostatic hypotension and a reason to postpone walking practice and report.

## 임상 시나리오

Safety Check Before Gait TrainingOrthostatic hypotension after stroke
Lying 136/82 mmHg and standing 110/70 mmHg is a 26 mmHg systolic fall: orthostatic hypotension.

Report it and postpone walking practice; he is at risk of fainting and falling.

Strength of 3/5 allows supported walking with a gait belt; word-finding pauses do not affect gait safety.

CautionA fall while taking aspirin increases the risk of injury and bleeding; recheck orthostatic vital signs before rescheduling.

## 핵심 개념

- **Orthostatic hypotension** — A fall of at least 20 mmHg systolic or 10 mmHg diastolic within minutes of standing.
- **Gait training** — Rehabilitation practice of walking with assistance to restore safe mobility.
- **Gait belt** — A belt placed around the client's waist that the helper holds to support and steady the client during walking.
- **Manual muscle testing** — Grading of muscle strength from 0 to 5; grade 3 means movement against gravity without resistance.

## 같은 주제 문제

- [Situation: A 68-year-old man is on the medical ward on day 4 after an ischemic stroke in t…](https://mymerci.kr/pages/nclex_q.php?qn_id=630316)
- [Situation: A 68-year-old man is on the medical ward on day 4 after an ischemic stroke in t…](https://mymerci.kr/pages/nclex_q.php?qn_id=630317)
- [Situation: A 68-year-old man is on the medical ward on day 4 after an ischemic stroke in t…](https://mymerci.kr/pages/nclex_q.php?qn_id=630318)
- [Situation: A 68-year-old man is on the medical ward on day 4 after an ischemic stroke in t…](https://mymerci.kr/pages/nclex_q.php?qn_id=630319)
- [Situation: A 72-year-old woman with Parkinson disease for 9 years is admitted to the medic…](https://mymerci.kr/pages/nclex_q.php?qn_id=630320)
- [Situation: A 72-year-old woman with Parkinson disease for 9 years is admitted to the medic…](https://mymerci.kr/pages/nclex_q.php?qn_id=630321)
- [Situation: A 72-year-old woman with Parkinson disease for 9 years is admitted to the medic…](https://mymerci.kr/pages/nclex_q.php?qn_id=630322)
- [Situation: A 72-year-old woman with Parkinson disease for 9 years is admitted to the medic…](https://mymerci.kr/pages/nclex_q.php?qn_id=630323)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._