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Patient Data
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

Obesity

Tobacco use

Male gender

Age

Hypertension

High cholesterol

Answer and Explanation

Correct Answer : B,C,F,G

Rationale:
A. Family history: A positive family history of aneurysm or cardiovascular disease increases risk but is a nonmodifiable factor. The nurse cannot intervene to change genetic predisposition, so it is excluded from modifiable teaching priorities.

B. Obesity: Excess body weight contributes to hypertension, atherosclerosis, and increased arterial wall stress, all of which accelerate aneurysm formation and growth. Weight management through diet and activity should be emphasized in teaching.

C. Tobacco use: Smoking is one of the most significant modifiable risk factors for aneurysm progression and rupture. Nicotine damages the vascular endothelium and promotes atherosclerotic changes, making smoking cessation a critical teaching point.

D. Male gender: Being male is an inherent, nonmodifiable risk factor associated with higher incidence of abdominal aortic aneurysms. It cannot be altered through intervention or lifestyle modification.

E. Age: Advancing age weakens arterial walls and increases aneurysm risk, but it is nonmodifiable and therefore not a focus of preventive teaching.

F. Hypertension: Elevated blood pressure increases mechanical stress on the aortic wall, accelerating aneurysm enlargement and rupture risk. Teaching should include adherence to antihypertensive medication, diet modification, and regular blood pressure monitoring.

G. High cholesterol: Hyperlipidemia promotes plaque buildup, weakening the vessel wall and impairing circulation. Diet, exercise, and adherence to lipid-lowering medications are essential to reduce vascular strain and aneurysm progression.

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Correct Answer is C

Explanation

A. Mannitol is an osmotic diuretic that pulls fluid into the intravascular space and promotes diuresis, so sustained hypervolemia is not expected.

B. Mannitol does not significantly affect blood glucose levels; hyperglycemia is more commonly associated with corticosteroids or dextrose solutions.

C. Mannitol causes fluid shifts from intracellular to extracellular spaces, which can dilute serum sodium and lead to hyponatremia.

D. Mannitol increases urine output; decreased urine output would be an abnormal finding and may indicate renal impairment.

A. Administer a benzodiazepine. B. Apply wrist restraints. C. Notify the rapid response team. D. Increase oxygen to 60%.

Correct Answer is B

Explanation

Rationale:
A. Administer a benzodiazepine: Sedation may worsen respiratory drive and cause hypoventilation in a recently extubated client. Benzodiazepines should only be used if agitation persists after addressing environmental and safety concerns, and under provider direction.

B. Apply wrist restraints: The client’s confusion and attempt to climb out of bed pose a high risk for accidental self-injury or removal of oxygen equipment. Applying soft wrist restraints temporarily ensures safety while further assessing for causes of confusion and notifying the healthcare provider.

C. Notify the rapid response team: The client is hemodynamically stable with normal oxygen saturation and respiratory effort. Calling the rapid response team is unnecessary unless there is evidence of acute deterioration, such as respiratory distress or loss of consciousness.

D. Increase oxygen to 60%: The oxygen saturation of 98% indicates adequate oxygenation at the current FiO₂. Increasing oxygen unnecessarily could suppress respiratory drive and does not address the underlying cause of confusion or unsafe behavior.

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Body system	Findings
Cardiovascular	Pedal pulse of 2+ or better Blood pressure of 120/74 mm Hg Capillary refill of 4 seconds in lower extremities
Neurovascular	Skin that is pale, cool to touch Pupils equal and nonresponsive to light Absence of numbness or tingling in feet
Renal Perfusion	Creatinine of 1.2 mg/dL (106 mmol/L) Client has urine output of 1,600 mL in 24 hours Decreased blood urea nitrogen (BUN) level of 9.8 mg/dL (3.50 mmol/L)

Patient Data 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

A client is to receive mannitol IV for increased intracranial pressure. Which outcome may result from the use of mannitol?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

A client with a C-7 spinal cord injury (SCI) is experiencing autonomic dysreflexia. The nurse should first assess the client for which precipitating factor?

The nurse is completing a neurological assessment on a client with a closed head injury. The Glasgow Coma Scale (GCS) score was 13 on admission. It is now assessed at 6. Which is the priority nursing intervention based on the client's current GCS?

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Exhibits

Patient Data
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.