A client has hypertension and high risk factors for cardiovascular disease.
The client is overwhelmed with the recommended lifestyle changes.
What action by the nurse is best?
Assess the client's support system.
Assist in finding one change the client can control.
Determine what stressors the client faces in daily life.
Inquire about delegating some of the client's obligations.
The Correct Answer is B
Choice A rationale
Assessing the client's support system is a valuable step, but it is not the best initial action. Overwhelmed clients need to feel a sense of control over their situation before they can effectively utilize external support. Focusing on one manageable change empowers the client, which is a more immediate and effective intervention for dealing with feelings of being overwhelmed.
Choice B rationale
Overwhelmed clients often feel a lack of control and competence. By assisting the client to identify and focus on a single, achievable lifestyle change, the nurse can help the client experience a sense of mastery and success. This positive experience can build confidence and motivation, making it more likely for the client to attempt and sustain further lifestyle changes.
Choice C rationale
While understanding a client's stressors is important for holistic care, this information may further overwhelm a client who is already feeling burdened. The immediate priority is to help the client feel capable of making a change. By first focusing on one small, manageable step, the nurse can begin to empower the client and then address broader stressors later.
Choice D rationale
Inquiring about delegating obligations may not be practical or appropriate for many clients and does not directly address the core issue of feeling overwhelmed by lifestyle changes. This suggestion externalizes the problem and does not empower the client to take control of their health. The focus should be on internal motivation and self-efficacy, not simply shifting responsibilities.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
The 44-year-old client with pneumonia receiving intravenous antibiotics is at some risk due to potential immobility and fever, which can lead to diaphoresis and skin maceration. However, this client is likely mobile enough to shift positions independently or with minimal assistance, reducing the risk of sustained pressure. The client's age and general health status, aside from the acute infection, suggest good tissue perfusion and skin integrity.
Choice B rationale
A 26-year-old who is bedridden with a fractured leg is at significant risk due to immobility. The inability to shift weight and relieve pressure on bony prominences can lead to ischemia and tissue damage. However, younger individuals generally have better vascular supply, skin turgor, and faster cellular regeneration compared to older adults, which provides some protective physiological advantage against pressure injury development.
Choice C rationale
This 65-year-old client is at the greatest risk due to a combination of multiple risk factors. Hemiparesis leads to immobility and the inability to reposition, causing prolonged pressure on one side of the body. Incontinence exposes the skin to moisture and chemical irritants from urine and feces, leading to maceration and a breakdown of the skin's protective barrier, making it more susceptible to injury.
Choice D rationale
A 78-year-old requiring a walker for ambulation is at a lower risk for pressure injuries compared to a bedridden individual. Although advanced age and the need for assistive devices suggest some mobility limitations, the ability to ambulate, even with assistance, indicates the capacity to shift weight and relieve pressure on a regular basis. This regular movement promotes circulation and prevents prolonged periods of immobility.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
An elevated low-density lipoprotein (LDL-C) level is a significant risk factor for atherosclerosis because LDL-C is the primary carrier of cholesterol to the tissues. High levels lead to the deposition of cholesterol within the arterial walls, forming atherosclerotic plaques. These plaques narrow arteries, impede blood flow, and can rupture, leading to thrombosis and acute cardiovascular events. A normal LDL-C level is typically less than 100 mg/dL.
Choice B rationale
Decreased levels of high-density lipoprotein cholesterol (HDL-C) are concerning because HDL-C plays a protective role in the cardiovascular system. HDL-C is responsible for reverse cholesterol transport, a process where it removes excess cholesterol from the arterial walls and transports it back to the liver for excretion. Low levels impair this protective mechanism, allowing cholesterol accumulation and plaque formation. A normal HDL-C level is typically above 40 mg/dL for men and 50 mg/dL for women.
Choice C rationale
Asian ethnicity is not considered an independent risk factor for atherosclerosis. While certain populations may have varying risk profiles due to genetic and lifestyle factors, ethnicity alone does not directly predispose an individual to the condition in the same manner as modifiable factors like dyslipidemia or smoking. A comprehensive risk assessment relies on established clinical and lifestyle factors, not solely on a person’s racial background.
Choice D rationale
A history of smoking is a major, modifiable risk factor for atherosclerosis. The chemicals in cigarette smoke damage the endothelium, the inner lining of blood vessels, making it more permeable to cholesterol. Smoking also increases inflammation, promotes platelet aggregation, and lowers HDL-C levels. These combined effects accelerate the formation and progression of atherosclerotic plaques, significantly increasing the risk of cardiovascular events like myocardial infarction and stroke.
Choice E rationale
A single blood pressure reading of 142/92 mm Hg, while elevated, is not sufficient for a diagnosis of hypertension or to be considered a definitive risk factor. Hypertension is diagnosed based on multiple elevated readings over time. While this reading is concerning, a single measurement can be influenced by various factors. The finding warrants further monitoring, but it does not represent a chronic risk factor until a pattern of sustained high blood pressure is established
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