A older adult client tells the nurse that of having a high-density lipoprotein (HDL) level of 85 mg/dL (2.2 mmol/L). Which action should the nurse take?

Reference Range:

High Density Lipoproteins (HDL) [greater than 45 mg/dL (greater than 0.75 mmol/L)]

Explain that the client may need medication therapy.

Ask the client about hereditary cardiac risk factors.

Confirm that this value is helpful in reducing cardiac risk.

Encourage the client to reduce consumption of fatty foods.

Answer and Explanation

The Correct Answer is C

Rationale

A. This is not appropriate because a high HDL level (85 mg/dL) is beneficial and does not typically necessitate medication therapy solely for raising HDL.

B. This is reasonable to assess overall cardiovascular risk factors, including hereditary factors, which can influence the management and prevention of heart disease.

C. It reinforces the positive impact of a high HDL level on reducing cardiovascular risk and provides the client with valuable information about their health status.

D. While dietary advice is important, specifically targeting fatty foods may not be necessary if the client's HDL level is already high. General dietary recommendations for heart health are beneficial but should be tailored to individual needs.

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Correct Answer is B

Explanation

Rationale

A. This action involves assessing the capillary refill of the lower extremity distal to the femoral site. It helps in evaluating peripheral perfusion and circulation to ensure there is no compromise to blood flow. This is important because decreased capillary refill could indicate impaired circulation, possibly due to arterial occlusion or hematoma formation.

B. Checking the femoral insertion site for hematoma formation is crucial after a cardiac catheterization. Hematomas can develop due to bleeding from the femoral artery puncture site, especially if the client is receiving anticoagulant therapy like heparin. A hematoma can compress surrounding structures, potentially causing pain and compromising circulation.

C. While it's important to assess the integrity of IV insertion sites, in this scenario, the primary concern is the groin insertion site used for cardiac catheterization. The IV insertion sites should be assessed regularly for signs of infiltration, phlebitis, or infection, but this should not take precedence over assessing the femoral insertion site for complications related to the procedure.

D. Deep breathing exercises are important for preventing respiratory complications such as atelectasis and pneumonia, especially in clients who are sedated and immobilized. However, in the context of acute pain at the femoral insertion site post-cardiac catheterization, assessing and addressing potential complications related to the procedure take priority.

A. Secure the room with padded walls and minimal furnishings. B. Provide one-on-one observation at all times. C. Release the client as soon as composure is regained. D. Observe for extrapyramidal symptoms, such as dystonia.

Correct Answer is D

Explanation

Rationale

A. While ensuring the room is secure and providing one-on-one observation are also important, the immediate concern after administering haloperidol is the potential for these side effects.

B. Continuous observation is crucial to monitor the client's behavior, mood, and safety while in seclusion. This allows the nurse to intervene promptly. However, monitoring should be specific

C. Seclusion is not intended as a punishment but as a therapeutic intervention to protect the client and others from harm during acute psychiatric episodes. The decision to release the client should be based on clinical assessment

D. Haloperidol is an antipsychotic medication that can cause extrapyramidal symptoms (EPS), including dystonia (muscle spasms). Monitoring for EPS is essential after administering haloperidol to ensure early detection and treatment, which may involve administering anticholinergic medications if EPS occurs.

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A older adult client tells the nurse that of having a high-density lipoprotein (HDL) level of 85 mg/dL (2.2 mmol/L). Which action should the nurse take? Reference Range: High Density Lipoproteins (HDL) [greater than 45 mg/dL (greater than 0.75 mmol/L)]

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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A older adult client tells the nurse that of having a high-density lipoprotein (HDL) level of 85 mg/dL (2.2 mmol/L). Which action should the nurse take?

Reference Range:

High Density Lipoproteins (HDL) [greater than 45 mg/dL (greater than 0.75 mmol/L)]