In assessing a client's major risk factors for heart disease, which of the following should the nurse include in the history?

Smoking, hypertension, obesity, diabetes, and hyperlipidemia.

Family history, stress, hypertension, and age.

Alcohol consumption, obesity, diabetes, stress, hyperlipidemia.

Personality type, hyperlipidemia, diabetes, and smoking.

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Smoking, hypertension, obesity, diabetes, and hyperlipidemia are all well-established risk factors for heart disease. Smoking damages the lining of the arteries, leading to a buildup of fatty material which narrows the artery. Hypertension can cause hardening and thickening of the arteries, which can lead to a heart attack or stroke. Obesity increases the likelihood of high blood pressure, high cholesterol levels, and diabetes, all of which are risk factors for heart disease. Diabetes increases the risk of heart disease significantly, as high blood sugar levels can damage blood vessels and the nerves that control the heart. Hyperlipidemia, particularly high levels of LDL cholesterol, can lead to plaque buildup in the arteries, increasing the risk of heart attack or stroke.

Choice B Reason:

Family history is a non-modifiable risk factor for heart disease, as genetics can play a role in an individual's likelihood of developing heart conditions. Stress can contribute to heart disease risk factors such as hypertension and is associated with other unhealthy behaviors. Hypertension and age are both significant risk factors; the risk of heart disease increases with age and with sustained high blood pressure.

Choice C Reason:

Alcohol consumption in excess can lead to high blood pressure, heart failure, or stroke. Obesity, diabetes, and stress are all risk factors as previously mentioned. Hyperlipidemia is also a modifiable risk factor that can be managed through diet, exercise, and medication.

Choice D Reason:

Personality type itself is not a direct risk factor for heart disease, but certain personality traits can lead to stress, which is a risk factor. Hyperlipidemia, diabetes, and smoking are all direct risk factors for heart disease as they contribute to the development of cardiovascular conditions.

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Correct Answer is C

Explanation

Choice A reason:
Administering an antiemetic is an important intervention in the PACU, especially if the patient is experiencing nausea or has a history of postoperative nausea and vomiting (PONV). However, it is not the first priority. Antiemetics work by blocking the neurotransmitters that trigger the vomiting reflex. Medications such as ondansetron or promethazine may be used.

Choice B reason:
Applying sequential compression devices is a preventive measure against deep vein thrombosis (DVT), which is a risk due to immobility after surgery. These devices help improve venous return from the lower limbs by applying intermittent pressure. While important, this intervention follows after the assessment of vital signs.

Choice C reason:
Assessing vital signs is the first and foremost priority when a patient is transferred to the PACU. Vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, provide immediate information about the patient's hemodynamic status and can indicate the need for urgent interventions. Any evidence of respiratory or circulatory compromise requires immediate attention.

Choice D reason:
Hanging the Lactated Ringers solution is part of managing the patient's fluid status postoperatively. Lactated Ringers is an isotonic solution that helps to replace lost fluids and maintain electrolyte balance. While important for patient care, it is not the initial priority upon arrival in the PACU.

A. Information about available community resources. B. When to return to the ED for follow-up care. C. Names and phone numbers of local attorneys who defend rape victims. D. The phone number of the battered women's shelter or safe house.

Correct Answer is A

Explanation

Choice A reason:
Providing information about available community resources is crucial for ongoing support and assistance. These resources can offer counseling, medical follow-up, legal advice, and other services that may be needed after such a traumatic event. Community resources play a vital role in the recovery process, offering a network of support and specialized services tailored to the needs of sexual assault survivors.

Choice B reason:
While it is important to know when to return to the ED for follow-up care, this is typically not the primary content of discharge instructions. Follow-up care is usually managed by primary care providers or specialists rather than the ED unless there are specific complications or concerns that need to be addressed immediately.

Choice C reason:
The names and phone numbers of local attorneys may be provided, but this is not standard for all discharge instructions. Legal support is important, but the immediate focus post-discharge is often on the survivor's physical and emotional well-being. Attorneys specializing in defending rape victims can be a part of the community resources provided to the survivor.

Choice D reason:
The phone number of a battered women's shelter or safe house may be included in discharge instructions, especially if there is an immediate need for safe accommodation. However, this is not the only resource that should be provided, and it is not specific to all cases of sexual assault.

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In assessing a client's major risk factors for heart disease, which of the following should the nurse include in the history?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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