Exhibits
After two days of intensive care, the client is transferred to the telemetry floor. The floor nurse is preparing a plan of care for the client.
Which modifiable risk factor(s) should the nurse include in the teaching for this client? Select all that apply.
Family history
Hypertension
Obesity
High cholesterol
Age
Male gender
Coronary artery disease
Tobacco use
Correct Answer : B,C,D,H
Rationale:
A. Family history: A family history of aneurysms or vascular disease is a non-modifiable risk factor. While it provides valuable context for risk assessment, it cannot be changed through behavioral interventions.
B. Hypertension: Elevated blood pressure contributes significantly to the development and progression of aortic aneurysms. Teaching the client to manage blood pressure through medications, diet, and lifestyle is essential to reducing further vascular damage.
C. Obesity: Excess body weight increases the strain on the cardiovascular system and is associated with elevated blood pressure, insulin resistance, and atherosclerosis. Weight management strategies should be emphasized in post-discharge education.
D. High cholesterol: Hyperlipidemia accelerates atherosclerosis, which weakens arterial walls and promotes aneurysm formation. Dietary changes, medication adherence, and lipid monitoring are important components of long-term care.
E. Age: Advancing age is a major risk factor for aortic aneurysms, especially in individuals over 65. However, it is non-modifiable and therefore not the focus of preventive teaching.
F. Male gender: Being male increases the risk of developing abdominal aortic aneurysms compared to females, but gender is non-modifiable. Patient education should instead focus on risks the client can change or control.
G. Coronary artery disease: While CAD and AAA share many of the same causes (like smoking and hypertension), CAD itself is a co-existing condition rather than a risk factor that can be modified to fix the aorta. However, managing the causes of CAD (like high cholesterol) is what the nurse would actually teach.
H. Tobacco use: Smoking is one of the strongest modifiable risk factors for aortic aneurysm development and rupture. Smoking cessation significantly decreases progression rates and improves overall vascular health.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Aspiration: Aspiration is typically a concern in clients with impaired swallowing, reduced consciousness, or neurologic disorders. Elevated parathyroid hormone (PTH) does not directly affect swallowing function or airway protection.
B. Falls: Elevated PTH levels cause hypercalcemia, which can lead to muscle weakness, fatigue, confusion, and bone demineralization. These effects increase the client’s risk for falls and fractures, making fall prevention a key safety priority.
C. Suicide: While chronic illness can impact mood, elevated PTH levels are not directly associated with suicidal ideation. Psychiatric monitoring is important but not the primary safety focus in this case.
D. Hypothermia: PTH imbalance does not significantly affect thermoregulation. Hypothermia is not a typical complication of elevated PTH levels and does not require focused preventive measures in this scenario.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Explanation
Rationale for Correct Choices:
- Cortisol, epinephrine, and norepinephrine: These are key stress hormones activated during the fight-or-flight response. In PTSD, their persistent elevation is associated with symptoms like anxiety, agitation, and increased alertness, especially during perceived threats.
- Hypervigilance: Hypervigilance refers to an enhanced state of sensory sensitivity and constant scanning of the environment for threats. It is a hallmark of PTSD, evident in the client's easily startled behavior and environmental scanning.
Rationale for Incorrect Choices:
- Acetylcholine, epinephrine, and norepinephrine: Acetylcholine plays a greater role in attention and memory, not the stress response. Cortisol, not acetylcholine, is a more relevant hormone in PTSD-related hyperarousal and stress regulation.
- Dopamine, norepinephrine, and epinephrine: While dopamine influences motivation and pleasure, cortisol is more directly tied to the physiological stress response seen in PTSD. Omitting cortisol weakens the connection to stress-induced hyperalertness.
- Bradyphrenia: Bradyphrenia refers to slowed thinking, which is not typical in hyperaroused PTSD states. The client shows heightened awareness, not cognitive slowing.
- Hypoactivity: Hypoactivity implies reduced movement or response, which does not align with the client’s constant environmental scanning and heightened alertness. Hyperactivity, not hypoactivity, is more consistent with hypervigilance.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.