The nurse measures a male client's waist circumference as 43 inches (109 cm). Which statement is most appropriate for the nurse to make given this finding?

"Let's discuss your risk factors for heart disease."

"We should review the amount of protein in your diet."

"Waist circumference can vary over the course of the day."

"You probably have a vitamin deficiency."

Answer and Explanation

The Correct Answer is A

A) "Let's discuss your risk factors for heart disease.":

A waist circumference of 43 inches (109 cm) in a male is considered elevated and indicates central obesity, which is a significant risk factor for cardiovascular diseases, including heart disease, hypertension, and type 2 diabetes. Addressing this finding by discussing risk factors for heart disease is appropriate and necessary for preventive healthcare.

B) "We should review the amount of protein in your diet.":

While diet is important, protein intake is not directly related to waist circumference. The primary concern with a large waist circumference is the associated risk of metabolic and cardiovascular conditions, rather than specific macronutrient consumption.

C) "Waist circumference can vary over the course of the day.":

Though there can be minor variations in waist circumference throughout the day due to factors like fluid retention or meals, a measurement of 43 inches is significantly above the threshold indicating central obesity. This warrants a discussion about health risks rather than focusing on daily fluctuations.

D) "You probably have a vitamin deficiency.":

Vitamin deficiencies are not directly indicated by waist circumference measurements. This statement is not appropriate given the finding, as the primary concern with a large waist circumference is its association with increased risk of chronic diseases rather than nutrient deficiencies.

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Correct Answer is C

Explanation

A. Nail Beds:

While peripheral cyanosis can cause bluish discoloration of the nail beds, central cyanosis is more indicative of systemic hypoxemia and is best assessed in areas with rich blood supply, such as the oral mucosa.

B. Sclera:

The sclera is more commonly used to assess for jaundice (yellowing) rather than cyanosis. Cyanosis is not typically visible in the sclera.

C. Oral Mucosa:

Central cyanosis is most accurately assessed in areas with high vascularization, such as the oral mucosa. This area provides a clear indication of oxygenation status and can reveal hypoxemia more reliably than peripheral sites.

D. Palms:

Similar to the nail beds, the palms can show signs of peripheral cyanosis but are not the primary site for assessing central cyanosis. The oral mucosa remains the best site for this assessment.

A. Inquire about family history of headaches. B. Review the client's medical record. C. Assess the client's blood pressure. D. Provide medication for pain relief.

Correct Answer is C

Explanation

(a) Inquire about family history of headaches:

While understanding the client's family history of headaches can be important for a comprehensive assessment, it is not the immediate priority. The description of "the worst headache" ever experienced could indicate a serious condition that needs urgent attention.

(b) Review the client's medical record:

Reviewing the client's medical record provides valuable information about their history and potential underlying conditions. However, given the severity of the reported headache, it is crucial to perform a more immediate physical assessment to rule out life-threatening conditions.

Assessing the client's blood pressure is a critical initial action. A severe headache can be a symptom of hypertensive crisis, stroke, or other serious conditions. High blood pressure could provide an immediate clue to the severity and cause of the headache, allowing for quicker intervention.

(d) Provide medication for pain relief:

Providing pain relief is important, but it should not be the first action without determining the cause of the headache. Administering medication without assessing the client's condition could mask symptoms of a potentially serious underlying issue such as a stroke or hypertensive emergency.

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The nurse measures a male client's waist circumference as 43 inches (109 cm). Which statement is most appropriate for the nurse to make given this finding?

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Naxlex Comprehensive Predictor Exams

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