A nurse is reinforcing teaching with a client who is at risk for hypertension. Which of the following risk reduction strategies should the nurse Include in the teaching?

Restrict alcohol intake to 350 mt. (12 oz) of wine per day.

Limit caloric intake to 2.500 calories per day.

Walk for 30 min 5 days per week.

Increase dietary intake of canned vegetables

Answer and Explanation

The Correct Answer is C

Rationale:

A. Restrict alcohol intake to 350 mL (12 oz) of wine per day: This recommendation exceeds the safe alcohol limit for individuals at risk for hypertension. For women, the limit is typically one drink per day, and for men, up to two.

B. Limit caloric intake to 2,500 calories per day: 2,500 calories may still be excessive for many individuals, especially those with sedentary lifestyles. Hypertension risk is more effectively reduced through balanced nutrition and physical activity, not just calorie limits.

C. Walk for 30 min 5 days per week: Regular aerobic exercise like walking improves cardiovascular health and is strongly recommended to prevent and manage hypertension. This frequency and duration align with guidelines to lower blood pressure and support overall wellness.

D. Increase dietary intake of canned vegetables: Canned vegetables often contain high sodium levels, which can contribute to elevated blood pressure. Clients at risk for hypertension should be encouraged to choose fresh or low-sodium alternatives to help control sodium intake.

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Correct Answer is A

Explanation

Rationale:

A. A client who has a firm fundus following a vaginal birth and reports continuous perineal pain of 8 on a scale of 0 to 10: Although the fundus is firm, severe continuous perineal pain may indicate complications such as hematoma or infection, requiring immediate assessment and intervention to prevent worsening condition.

B. A client who is 30 hr postpartum and reports feeling tearful and overwhelmed: Postpartum emotional lability is common in this timeframe and generally not an immediate safety concern. The nurse should provide support but this client’s condition is not urgent.

C. A client who is 12 hr postpartum and reports having to urinate frequently: Frequent urination postpartum may be due to diuresis or normal bladder function return and is not typically urgent unless accompanied by other signs of infection or retention.

D. A client who had a cesarean birth yesterday and reports burning incision pain of 5 on a scale of 0 to 10: Moderate incision pain is expected after surgery and can be managed with analgesics; it does not require immediate intervention compared to potential perineal complications.

A. "Your child should have surgery in 7 to 10 days to remove the tumor." B. "You should not palpate your child's abdomen prior to surgery." C. "You should give your child captopril 200 mg PO daily." D. "Your child will not require further treatment after removal of the tumor.”

Correct Answer is B

Explanation

Rationale:

A. "Your child should have surgery in 7 to 10 days to remove the tumor.": Surgical removal of the tumor is a priority and is usually scheduled promptly after diagnosis, not delayed by a week or more. Early intervention reduces the risk of tumor rupture or metastasis.

B. "You should not palpate your child's abdomen prior to surgery.": Avoiding abdominal palpation is crucial because Wilms’ tumors are highly vascular and encapsulated. Palpation could cause rupture, leading to tumor cell spread into the peritoneal cavity and increasing the risk of metastasis.

C. "You should give your child captopril 200 mg PO daily.": Captopril is not a standard medication in the treatment of Wilms’ tumor. It is an antihypertensive that may be used if the child has associated hypertension, but the dosage listed is excessive for pediatric use and should not be prescribed without specific indications.

D. "Your child will not require further treatment after removal of the tumor.": Most children require additional therapy, such as chemotherapy and/or radiation, depending on tumor staging. Surgical removal alone is rarely curative, particularly in advanced or bilateral cases.

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A nurse is reinforcing teaching with a client who is at risk for hypertension. Which of the following risk reduction strategies should the nurse Include in the teaching?

Nursing Test Bank

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