Nokea
The nurse is assessing a 39-year-old Caucasian client with a blood pressure (BP) of 152/92 mm Hg at rest, a total cholesterol level of 180 mg/dL (4.5 mmol/L), and a fasting blood glucose level of 90 mg/dL (5.14 mmol/L). On which risk factor for coronary artery disease should the nurse place priority?
- A. Age
- B. Hypertension
- C. Hyperlipidemia
- D. Glucose intolerance
Correct Answer: B
Rationale: Hypertension, cigarette smoking, and hyperlipidemia are major risk modifiable factors for coronary artery disease. Glucose intolerance, obesity, and response to stress are also contributing factors. An age of more than 40 years is a nonmodifiable risk factor. A cholesterol level of 180 mg/dL (4.5 mmol/L) and a blood glucose level of 90 mg/dL (5.14 mmol/L) are within the normal range. The nurse places priority on major risk factors that need modification.
You may also like to solve these questions
The mother whose child is generally alert and participates well in classroom activities is concerned that the teacher now reported that the child has frequent periods during the day when he appears to be staring off into space. The nurse should suspect that the child has which problem?
- A. School phobia
- B. Absence seizures
- C. Behavioral problem
- D. Attention-deficit/hyperactivity syndrome
Correct Answer: B
Rationale: Absence seizures are a type of generalized seizure. They consist of a sudden, brief (usually 5 to 10 seconds) arrest of the child's motor activities accompanied by a blank stare and a loss of awareness. The child's posture is maintained at the end of the seizure, and the child returns to activity that was in process as though nothing has happened. School phobia includes physical symptoms that usually occur at home and that may prevent the child from attending school. Behavior problems would be noted by more overt symptoms than the ones described in this question. A child with attention-deficit/hyperactivity syndrome becomes easily distracted, is fidgety, and has difficulty following directions.
The mother explains that after meals her infant has been vomiting, and now it is becoming more frequent and forceful. During the assessment, the nurse notes visible peristaltic waves moving from left to right across the infant's abdomen. On the basis of these findings, which condition should the nurse suspect?
- A. Colic
- B. Intussusception
- C. Congenital megacolon
- D. Hypertrophic pyloric stenosis
Correct Answer: D
Rationale: In pyloric stenosis, the vomitus contains sour, undigested food but no bile, the child is constipated, and visible peristaltic waves move from left to right across the abdomen. A movable, palpable, firm, olive-shaped mass in the right upper quadrant may be noted. Crying during the evening hours, appearing to be in pain, but eating well and gaining weight are clinical manifestations of colic. An infant who suddenly becomes pale, cries out, and draws the legs up to the chest is demonstrating physical signs of intussusception. Ribbon-like stool, bile-stained emesis, the absence of peristalsis, and abdominal distention are symptoms of congenital megacolon (Hirschsprung's disease).
The nurse caring for a child diagnosed with kidney disease is analyzing the child's laboratory results and notes a sodium level of 148 mEq/L (148 mmol/L). On the basis of this finding, which clinical manifestation should the nurse expect to note in the child?
- A. Lethargy
- B. Diaphoresis
- C. Cold, wet skin
- D. Dry, sticky mucous membranes
Correct Answer: D
Rationale: Hypernatremia occurs when the sodium level is more than 145 mEq/L (145 mmol/L). Clinical manifestations include intense thirst, oliguria, agitation, restlessness, flushed skin, peripheral and pulmonary edema, dry and sticky mucous membranes, nausea, and vomiting. None of the remaining options are associated with the clinical manifestations of hypernatremia.
The nurse is caring for an infant admitted to the hospital with a diagnosis of hemolytic disease. Which finding should the nurse expect to note in this infant when reviewing the laboratory results?
- A. Decreased bilirubin count
- B. Elevated blood glucose level
- C. Decreased red blood cell count
- D. Decreased white blood cell count
Correct Answer: C
Rationale: The two primary pathophysiological alterations associated with hemolytic disease are anemia and hyperbilirubinemia. The red blood cell count is decreased because red blood cell production cannot keep pace with red blood cell destruction. Hyperbilirubinemia results from the red blood cell destruction that accompanies this disorder and from the normally decreased ability of the neonate's liver to conjugate and excrete bilirubin efficiently from the body. Hypoglycemia is associated with hypertrophy of the pancreatic islet cells and increased levels of insulin. The white blood cell count is not related to this disorder.
The nurse is developing a plan of care for a client in Buck's (extension) traction. The nurse should determine that which is a priority client problem?
- A. Immobility
- B. Risk of infection
- C. Altered independence
- D. Insufficient sensory stimulation
Correct Answer: A
Rationale: The priority client problem in Buck's traction is immobility. Options 3 and 4 may also be appropriate for the client in traction, but immobility presents the greatest risk for the development of complications. Buck's traction is a skin traction, and there are no pin sites.