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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,G,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: Although not modifiable in itself, many contributing factors to CAD—such as diet, activity level, and smoking—can be addressed. Risk factor management helps prevent complications and progression of vascular disease.

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 []

Explanation

Rationale for Correct Choices:

Alcohol withdrawal: The client's tachycardia, low-grade fever, tremulousness, agitation, and recent cessation of alcohol use suggest early alcohol withdrawal. The presence of a 10-year drinking history and neurological symptoms also supports this condition.
Implement seizure precautions: Seizure risk increases in alcohol withdrawal, especially within 6–48 hours of last intake. Safety measures are essential to reduce harm from potential seizures during detoxification.
Infuse thiamine: Chronic alcohol use often causes thiamine deficiency, which can lead to Wernicke's encephalopathy. Thiamine should be administered before glucose to prevent neurologic complications.
Seizure activity: Monitoring for seizures is crucial as withdrawal-related seizures are a common and dangerous complication in alcohol-dependent clients undergoing detox.
Vital signs: Autonomic instability (e.g., elevated blood pressure and heart rate) occurs during withdrawal. Frequent monitoring can help detect progression to delirium tremens.

Rationale for Incorrect Choices:

Increased intracranial pressure: Although the client has a head laceration, there is no loss of consciousness, vomiting, or abnormal GCS, making ICP less likely as the primary concern at this stage.
Pneumonia: There is no productive cough, lung involvement, abnormal lung sounds, or elevated white blood cell count to indicate pneumonia.
Anaphylaxis: The client’s symptoms do not suggest an allergic reaction, there is no rash, airway involvement, or sudden hypotension.
Administer albuterol: This is used for bronchospasm or asthma. The client has no respiratory distress, wheezing, or bronchoconstriction signs requiring bronchodilators.
Call rapid response: The client is stable and alert, with no sudden life-threatening deterioration, so rapid response is not necessary.
Insert central venous pressure (CVP) monitor: CVP monitoring is invasive and reserved for critically ill patients needing fluid status evaluation, not indicated in early alcohol withdrawal.
White blood cells: WBC count is more relevant for infection monitoring, which is not currently the primary issue in this presentation.
Glasgow Coma Scale: Although helpful if neurological deterioration is suspected, the client is alert and interactive, making GCS unnecessary as a routine measure in this case.
Monitor intracranial pressure (ICP): There is no evidence of head trauma severity or neurological decline warranting ICP monitoring at this time.

A. Monitoring effects of oxytocin administration to help achieve cervical dilation. B. Assessing the fetal heart rate and pattern for signs of fetal distress. C. Providing pain medication to increase the client's tolerance of labor pains. D. Assisting the client to push effectively so that expulsion of the fetus can be achieved.

Correct Answer is D

Explanation

Rationale:

A. Monitoring effects of oxytocin administration to help achieve cervical dilation: This is appropriate during the first stage of labor. The second stage begins after full dilation, so oxytocin’s role in cervical change is no longer relevant at this point.

B. Assessing the fetal heart rate and pattern for signs of fetal distress: FHR monitoring is important throughout labor, including the second stage, but it is not unique to this phase. It supports safe delivery but does not directly facilitate the main goal of this stage—fetal expulsion.

C. Providing pain medication to increase the client's tolerance of labor pains: Pain management is crucial, but narcotics are typically avoided in the second stage due to potential neonatal respiratory depression. Also, this does not address the primary task of this stage.

D. Assisting the client to push effectively so that expulsion of the fetus can be achieved:
This is the hallmark intervention of the second stage of labor, where full dilation has occurred and the goal is delivery of the baby. Supporting effective pushing directly aids in achieving this outcome.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

Which nursing intervention is indicated for the second stage of labor?

Correct Answer is D

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.