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.

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Correct Answer is C

Explanation

A. The hot water heater is set to 47° C (117° F).This temperature is within a safe range to prevent burns while ensuring adequate hot water for hygiene.

B. Grab bars are installed in the shower.Grab bars provide support and help prevent falls in older adults, especially those with osteoporosis who are at higher risk for fractures.

C. There is an area rug covering a tile floor.Area rugs are a significant tripping hazard, especially for older adults with osteoporosis, as a fall could lead to fractures. The nurse should intervene to recommend removing or securing the rug to reduce the risk of falls.

D. Prescriptions are stored in a medication organizer.A medication organizer helps older adults manage their medications effectively and reduces the risk of missed or incorrect doses.

A. An assistive personnel prevents a client from leaving the facility. B. An assistive personnel discusses client care in the facility cafeteria with visitors present. C. A nurse administers a medication without first identifying the client. D. A nurse begins a blood transfusion without obtaining consent from a client.

Correct Answer is C

Explanation

A. An assistive personnel prevents a client from leaving the facility:

This situation may raise ethical concerns related to patient autonomy and freedom of movement. However, it is not a clear example of negligence. Negligence is more directly related to the provision of care and the failure to meet the standard of care.

B. An assistive personnel discusses client care in the facility cafeteria with visitors present:

This situation involves a breach of confidentiality and may violate the Health Insurance Portability and Accountability Act (HIPAA). However, it is not an example of negligence. Negligence typically involves a failure to provide appropriate care rather than a breach of privacy.

C. A nurse administers a medication without first identifying the client:

This is an example of negligence. Negligence refers to the failure to provide the standard of care that a reasonably prudent person would have provided under similar circumstances. In this case, administering medication without first identifying the client is a breach of the standard of care, and it can lead to serious consequences, including harm to the patient.

D. A nurse begins a blood transfusion without obtaining consent from a client:

This is an example of a legal issue related to lack of informed consent. While it raises ethical and legal concerns, it may not necessarily be considered negligence, which is more related to a failure in providing care up to the standard. However, it is still a serious violation of ethical and legal principles.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A home health nurse is assessing the home environment of an older adult client who has osteoporosis. For which of the following findings should the nurse intervene?

Correct Answer is C

Explanation

A nurse is collaborating with a risk management team about potential legal issues involving client care. The nurse should identify that which of the following situations is an example of negligence?

Correct Answer is C

Explanation

A nurse is preparing to administer medications to a client. At which of the following times should the nurse compare the medication administration record and the medication label? (Select all that apply.)

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A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client's motivation to learn?

A nurse in a provider's office is caring for a client. Exhibits The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for osteoporosis? (Select all that apply.)