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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

Answer and Explanation

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.

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

Explanation

Rationale:

A. Shaking that changes the child's handwriting legibility: Sudden onset of tremors affecting fine motor skills may indicate a neurological issue, such as a seizure disorder or early signs of a neurological condition, and requires prompt evaluation by the school nurse.

B. Bruises on both knees after the weekend: Bruises on the knees in children are often consistent with normal play and activity. Unless the bruises are unusual in pattern or location (e.g., upper arms, back), they typically do not require immediate referral.

C. Sunburn with blisters on the face, arms, and hands: Blistering sunburns can lead to dehydration, pain, and secondary infection. Facial involvement and blistering elevate the severity and warrant assessment and possible treatment recommendations.

D. Refuses to complete written homework assignments: While this behavior might suggest learning or behavioral challenges, it is not an urgent health issue requiring immediate referral. Teachers should monitor and possibly refer through academic support services, not directly to the nurse.

E. Thirst and frequent requests for bathroom breaks: These symptoms could be early signs of undiagnosed diabetes mellitus and warrant immediate attention from the school nurse to initiate further assessment and notify the child’s guardian.

A. Use fans to provide external cooling. B. Encouraging liberal fluid intake. C. Encourage the client to eat a bland diet. D. Cover the client with warm blankets.

Correct Answer is B

Explanation

Rationale:

A. Use fans to provide external cooling: While fans can help reduce temperature, they may cause chills or discomfort if used excessively. Internal cooling through medication and hydration is more effective and safer than relying on environmental cooling measures alone.

B. Encouraging liberal fluid intake: Fever increases insensible fluid losses through sweating and rapid breathing. Promoting fluid intake helps maintain hydration, supports thermoregulation, and assists the body in clearing toxins or infections more efficiently.

C. Encourage the client to eat a bland diet: Dietary considerations are not directly related to fever reduction. While bland foods may help during illness, they are not a primary intervention after administering an antipyretic.

D. Cover the client with warm blankets: Covering the client with warm blankets may increase body temperature and interfere with the medication’s effect. It is important to avoid excessive warmth after giving an antipyretic, unless the client is shivering or reports feeling cold.

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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.

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Naxlex Comprehensive Predictor Exams

The school nurse is preparing a presentation for elementary school teachers to inform them when a child should be referred to the school clinic for further follow-up. The teachers should be instructed to report which situations to the school nurse? Select all that apply.

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

Explanation

After administering an antipyretic medication, which intervention should the nurse implement?

Correct Answer is B

Explanation

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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.

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.