During a routine assessment at an outpatient clinic, the nurse notes that a client has abdominal obesity and a high waist-hip ratio, with a body mass index of 32 kg/m2.
Which action(s) should the nurse take in response to these findings? (Select all that apply.)
Measure the client's blood pressure in both arms.
Screen for a family history of diabetes mellitus.
Arrange for immediate transport to a medical facility.
Advise the client to restrict fluids and keep feet elevated.
Discuss the importance of a regular exercise program.
Correct Answer : A,B,E
Choice A rationale:
Measuring blood pressure in both arms can help assess for potential hypertension, which is a common concern in individuals with abdominal obesity and a high waist-hip ratio.
Choice B rationale:
Screening for a family history of diabetes mellitus is important because individuals with abdominal obesity are at increased risk for type 2 diabetes.
Choice C rationale:
Immediate transport to a medical facility is not indicated based solely on the findings of abdominal obesity, high waist-hip ratio, and elevated BMI. These findings may indicate an increased risk for certain health conditions, but they do not necessitate emergency transport.
Choice D rationale:
Restricting fluids and elevating feet is not a standard intervention based solely on the findings described. This action would be more relevant in specific medical situations, such as managing edema.
Choice E rationale:
Discussing the importance of a regular exercise program is appropriate because it can help address obesity and its associated health risks, including diabetes and hypertension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"B"}
Explanation
Choice A rationale:
Sinus tachycardia is not a cause, but a consequence of hyperkalemia.
Choice B rationale:
The client has a history of diabetes, hypertension, coronary artery disease, and end-stage renal disease, which are all risk factors for developing hyperkalemia (high levels of potassium in the blood). She also missed her scheduled dialysis session, which could have caused a buildup of potassium in her blood. Some of the signs and symptoms of hyperkalemia include fatigue, weakness, muscle cramps, tingling sensation in arms and legs, and cardiac arrhythmias such as sinus tachycardia (a fast heart rate). The other options are not consistent with the client's data or condition.
Choice C rationale:
Hypermagnesemia can also cause muscle weakness and cardiac arrhythmias, but they are less likely in this scenario since magnesium is not affected by dialysis
Choice D rationale:
Hypokalemia can also cause muscle weakness and cardiac arrhythmias, but they is less likely in this scenario since potassium is usually elevated in ESRD.
Correct Answer is A
Explanation
Choice A Rationale:
Ecchymotic blood accumulations (bruises) are indicative of possible trauma or injury to the scalp. In this case, it suggests that the hair loss is likely due to physical manipulation (such as pulling or arranging the hair to cover bald spots) rather than a medical condition.
Choice B rationale:
This choice suggests that evidence of patches of lost hair would be indicative of non-disease-related hair loss. However, this is not necessarily true. Medical conditions, such as alopecia areata, can also cause patchy hair loss without physical trauma. Therefore, it is not a definitive indicator that hair loss is not disease-related.
Choice C rationale:
Episodic complaints of pruritus (itching) could be associated with various scalp conditions, including those that lead to hair loss. Itching alone does not rule out disease-related hair loss. In fact, some medical conditions can cause both itching and hair loss.
Choice D rationale:
Erythema (redness) of localized lesions may suggest inflammation but does not necessarily indicate non-disease-related hair loss. Medical conditions can also cause localized inflammation and hair loss.
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