A nurse is caring for a client.

Medical History

0800

Client has a history of hyperlipidemia, rheumatoid arthritis, and hypertension.

Client has a BMI of 32

Client has a family history of colon cancer.

The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for heart disease? (Select all that apply)

Cholesterol level

History of hyperlipidemia

History of hypertension

History of rheumatoid arthritis

Family history

Answer and Explanation

Correct Answer : A,B,C

A. Cholesterol level: Elevated cholesterol levels are a risk factor for heart disease. High levels of low-density lipoprotein (LDL) cholesterol and low levels of high-density lipoprotein (HDL) cholesterol are associated with an increased risk of cardiovascular disease.

B. History of hyperlipidemia: Hyperlipidemia refers to elevated levels of lipids (fats) in the blood, including cholesterol and triglycerides. A history of hyperlipidemia indicates a pre-existing condition that can contribute to the risk of heart disease.

C. History of hypertension: Hypertension (high blood pressure) is a significant risk factor for heart disease. It can lead to damage to the arteries, increasing the risk of atherosclerosis (narrowing and hardening of the arteries) and other cardiovascular complications.

Explanation:

D. History of rheumatoid arthritis: While rheumatoid arthritis is an autoimmune condition that primarily affects the joints, it is not a direct risk factor for heart disease. However, people with rheumatoid arthritis may have an increased risk of cardiovascular disease due to inflammation.

E. Fasting glucose level: The fasting glucose level is related to diabetes rather than heart disease. However, diabetes is a significant risk factor for heart disease, so managing glucose levels is crucial for overall cardiovascular health.

F. Family history: While a family history of heart disease can contribute to an individual's overall risk, it is not a direct finding in the medical record that places the client at risk. The specific risk factors mentioned earlier (cholesterol level, history of hyperlipidemia, and history of hypertension) are more direct indicators of cardiovascular risk.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. "I will walk three times per week."

Weight-bearing exercises like walking help strengthen bones and reduce the risk of osteoporosis. Regular physical activity is a key component in maintaining bone health.

B. "I will take 250 milligrams of calcium once per day."

This amount of calcium is insufficient. The recommended daily intake for older adults is typically around 1,000 to 1,200 milligrams of calcium per day, divided into doses for better absorption.

C. "I will decrease my intake of dairy products."

Dairy products are rich sources of calcium and are beneficial for bone health. Decreasing their intake would not be advisable for reducing the risk of osteoporosis.

D. "I will avoid exposure to the sun."

Sun exposure helps the body produce vitamin D, which is essential for calcium absorption and bone health. Avoiding sun exposure could lead to a deficiency in vitamin D, increasing the risk of osteoporosis.

A. "The higher the score, the higher the pressure injury risk." B. The client's age is part of the measurement." C. "Each element has a range from one to five points." D. "The scale measures six elements."

Correct Answer is D

Explanation

A. "The higher the score, the higher the pressure injury risk.":The Braden Scale measures pressure injury risk, but a higher score indicates a lower risk of developing a pressure injury.

B. "The client's age is part of the measurement.":The client’s age is not a direct factor measured by the Braden Scale.

C. "Each element has a range from one to five points.":Each element in the Braden Scale is scored from 1 to 4 points. A score of 1 indicates the highest level of impairment for that element, while a score of 4 indicates the least impairment.

D. "The scale measures six elements.":

The Braden Scale evaluates six elements:Sensory perception,Moisture,Activity,Mobility,NutritionandFriction/shear. These elements are critical for assessing a client’s risk of developing pressure injuries.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching an older adult client about reducing the risk for osteoporosis. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is planning care for a client who is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include?

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A nurse is planning care for a client who is immobile. Which of the following actions should the nurse include in the plan of care?

A nurse is teaching a client who has decreased mobility about passive range-of-motion exercises. Which of the following statements should the nurse make?

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