A nurse in a provider's office is reviewing data from a client's medical record.
Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?

Orthostatic hypotension.

BMI of 24.

Type 1 diabetes mellitus.

Family history of osteoporosis.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Orthostatic hypotension is characterized by a sudden drop in blood pressure when standing up, often due to dehydration, medication side effects, or autonomic dysfunction. While concerning, it is not a direct risk factor for cardiovascular disease.

Choice B rationale

A BMI of 24 is within the normal range (18.5–24.9) and is not considered a risk factor for cardiovascular disease. Maintaining a healthy BMI is part of cardiovascular disease prevention.

Choice C rationale

Type 1 diabetes mellitus significantly increases the risk of cardiovascular disease due to its impact on blood vessels and the heart. It is a well-documented risk factor requiring careful management.

Choice D rationale

A family history of osteoporosis is relevant for bone health but does not directly increase the risk of cardiovascular disease. Cardiovascular risk factors are more closely related to metabolic and lifestyle factors.

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Correct Answer is ["660"]

Explanation

Step 1: Convert all liquid intake to mL: 8 oz of milk = 8 oz × 30 mL/oz = 240 mL 10 oz of water = 10 oz × 30 mL/oz = 300 mL 4 oz of gelatin = 4 oz × 30 mL/oz = 120 mL

Step 2: Sum the liquid intake: Total intake = 240 mL + 300 mL + 120 mL = 660 mL

The nurse should record 660 mL on the I&O.

A. Pad bony prominences before applying a restraint. B. Tie the ends of the restraint to the client's bed rail. C. Use a square knot to secure the client's restraint to the bed. D. Observe the client's skin integrity every 2 hr. E. Ensure that 2 fingers can be placed between the restraint and the client.

Correct Answer is ["A","D","E"]

Explanation

Choice A rationale

Padding bony prominences helps prevent skin breakdown and pressure ulcers, which are critical considerations when using restraints to avoid additional complications for the client.

Choice B rationale

Tying restraints to the bed rail is unsafe because it can lead to injury if the bed rail is moved. Restraints should be tied to the bed frame to prevent accidental harm.

Choice C rationale

Using a square knot for restraints is inappropriate as it is difficult to untie quickly in an emergency. Quick-release knots are recommended for safety and efficiency.

Choice D rationale

Observing the client's skin integrity every 2 hours is essential to detect early signs of skin breakdown and take preventive actions to ensure the client's comfort and safety.

Choice E rationale

Ensuring that two fingers can fit between the restraint and the client ensures that the restraint is not too tight, allowing for circulation and reducing the risk of injury.

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A nurse in a provider's office is reviewing data from a client's medical record.Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is recording the intake and output (I&O) for a client. The client consumed 8 oz of milk, 10 oz of water, 4 oz of gelatin, 1 egg, 1 piece of bacon, and 2 biscuits. Which volume should the nurse record on the I&O?

Correct Answer is ["660"]

Explanation

A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about the proper use of restraints.Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

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A nurse in a provider's office is reviewing data from a client's medical record.
Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?