A 48-year-old male client was admitted in CCU.
In assessing a client's major risk factors for heart disease, which should the nurse include when taking the client's subjective data?
Alcohol consumption, obesity, diabetes, stress, high cholesterol.
Smoking, hypertension, obesity, diabetes, high cholesterol.
Personality type, high cholesterol, diabetes, smoking.
Family history, hypertension, stress, age.
The Correct Answer is B
Choice A rationale
Alcohol consumption, obesity, diabetes, stress, and high cholesterol are all significant risk factors for heart disease. However, smoking is not listed in this choice. Smoking is a major risk factor for heart disease as it damages the lining of the arteries, leads to the build-up of fatty deposits (atherosclerosis), and increases the risk of heart attacks and strokes.
Choice B rationale
Smoking, hypertension, obesity, diabetes, and high cholesterol are all major risk factors for heart disease. Smoking contributes to the development of atherosclerosis and increases the risk of heart attacks. Hypertension, or high blood pressure, strains the heart and blood vessels, increasing the risk of heart disease. Obesity is linked to multiple risk factors, including high cholesterol, diabetes, and hypertension. Diabetes can cause damage to blood vessels and increase the risk of cardiovascular complications. High cholesterol contributes to the formation of plaques in the arteries, leading to atherosclerosis.
Choice C rationale
Personality type is not a major risk factor for heart disease. Although certain personality traits, such as Type A behavior (characterized by competitiveness, urgency, and hostility), have been associated with increased stress and a higher risk of cardiovascular events, they are not considered primary risk factors. High cholesterol, diabetes, and smoking are significant risk factors, but this choice does not include hypertension or obesity, which are also crucial risk factors for heart disease.
Choice D rationale
Family history, hypertension, stress, and age are important risk factors for heart disease, but this choice does not include some key factors such as smoking, obesity, or diabetes. Family history of heart disease can indicate a genetic predisposition to cardiovascular conditions. Hypertension and stress contribute to cardiovascular risk, and age is a non-modifiable risk factor as the risk of heart disease increases with age. However, the absence of smoking, obesity, and diabetes makes this choice less comprehensive in assessing heart disease risk factors. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Rhonchi are low-pitched, continuous breath sounds that are often indicative of secretions in the large airways. These sounds may change or clear with coughing, so the nurse should have the patient cough and then auscultate again to reassess the presence of rhonchi.
Choice B rationale
Wheezes are high-pitched, musical sounds heard primarily during expiration. They are caused by narrowed airways, typically due to asthma or other obstructive lung conditions. Wheezes do not usually clear with coughing and require specific treatments to address airway constriction.
Choice C rationale
Crackles are discontinuous, popping sounds heard during inspiration and are associated with fluid in the alveoli, such as in conditions like pneumonia or heart failure. Crackles are not typically cleared by coughing and may persist despite the patient's efforts to clear their airways.
Choice D rationale
Stridor is a high-pitched, harsh sound heard during inspiration, often indicating upper airway obstruction. Stridor is a medical emergency and requires immediate intervention to secure the airway. It does not clear with coughing and signifies a critical respiratory issue. .
Correct Answer is D
Explanation
Choice A rationale
A decreased angle between the cuticles and the nails is not indicative of clubbing. In fact, it is often associated with healthy nails. Clubbing is recognized by changes that increase the angle between the nail bed and the cuticle.
Choice B rationale
An upward curving of the nails, known as koilonychia or spoon nails, is not characteristic of clubbing but is often associated with iron-deficiency anemia. Hence, this answer is incorrect for clubbing.
Choice C rationale
Blue nails indicate cyanosis, which is related to a lack of oxygen in the blood. This is distinct from clubbing, which is more about the shape and angle of the nails rather than their color.
Choice D rationale
Clubbing is recognized by an increase in the angle between the nail bed and the cuticle, often greater than 160 degrees. This is a hallmark feature and the correct indicator of clubbing.
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