Nokea
The nurse is teaching a class on arterial essential hypertension. Which modifiable risk factors would the nurse include when preparing this presentation?
- A. Include information on retinopathy and nephropathy.
- B. Discuss sedentary lifestyle and smoking cessation.
- C. Include discussions on family history and gender.
- D. Provide information on a low-fiber and high-salt diet.
Correct Answer: B
Rationale: Modifiable risk factors for hypertension include sedentary lifestyle and smoking (B), which can be changed. Retinopathy/nephropathy (A) are complications, family history/gender (C) are non-modifiable, and low-fiber/high-salt (D) promotes hypertension.
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Which activity should the nurse encourage for a client with heart failure?
- A. Walking at a slow pace daily.
- B. Lifting heavy weights.
- C. Running for 30 minutes daily.
- D. Remaining on bedrest.
Correct Answer: A
Rationale: Low-intensity exercise like walking improves cardiovascular fitness without overstraining the heart.
The nurse is admitting a client diagnosed with peripheral vascular disease. Which data support a diagnosis of venous insufficiency?
- A. The client has bright red skin on the lower extremities.
- B. The client has a brownish purple area on the lower legs.
- C. The client complains of pain after ambulating for short distances.
- D. The client has nonhealing wounds on the toes and ankles.
Correct Answer: B
Rationale: Brownish purple skin (B) indicates hemosiderin from venous stasis. Red skin (A) is nonspecific, pain with walking (C) is arterial, and toe/ankle wounds (D) are arterial.
Which teaching point should the nurse include for a client with peripheral artery disease? Select all that apply.
- A. Inspect feet daily for sores or injuries.
- B. Wear tight shoes to support the feet.
- C. Stop smoking to improve blood flow.
- D. Exercise until pain occurs, then rest.
- E. Apply lotion to dry skin on legs.
- F. Avoid crossing legs when sitting.
Correct Answer: A,C,D,E,F
Rationale: Inspecting feet, stopping smoking, exercising with rest, applying lotion, and avoiding leg crossing promote circulation and prevent complications in peripheral artery disease.
The client diagnosed with essential hypertension is taking a loop diuretic daily. Which assessment data would require immediate intervention by the nurse?
- A. The telemetry reads normal sinus rhythm.
- B. The client has a weight gain of 2 kg within 1 to 2 days.
- C. The client's blood pressure is 148/92.
- D. The client's serum potassium level is 4.5 mEq.
Correct Answer: B
Rationale: Weight gain of 2 kg in 1–2 days (B) indicates fluid retention, a serious issue in hypertension requiring intervention. Normal sinus rhythm (A), BP 148/92 (C), and K+ 4.5 (D) are not urgent.
The nurse is assessing a client with heart failure. Which finding indicates worsening condition?
- A. Weight gain of 3 pounds in 2 days
- B. Blood pressure of 120/80 mmHg
- C. Heart rate of 70 beats per minute
- D. Clear lung sounds bilaterally
Correct Answer: A
Rationale: Rapid weight gain in heart failure indicates fluid retention, a sign of worsening condition.