Concepts of Nursing II Week 7 HESI 1 266
- Medical surgical (100% Verified)
Questions & Answers Latest Update.
The nurse is providing dietary instructions to a 68-year-old client who is at high
risk for development of coronary heart disease (CHD). Which information should
the nurse include?
Limit dietary selection of cholesterol to 300 mg per day.
Increase intake of soluble fiber to 10 to 25 grams per day.
Decrease plant stanols and sterols to less than 2
grams/day. Ensure saturated fat is less than 30% of
total caloric intake. Rationale
To reduce risk factors associated with coronary heart disease, the daily intake of
soluble fiber should be increased to between 10 and 25 gm. According to the
American Heart Association, soluble fibers help reduce the LDL cholesterol
levels.
Despite several eye surgeries, a 78-year-old client who lives alone has persistent
vision problems. The visiting nurse is discussing home safety hazards with the
client. The nurse suggests that the edges of the steps be painted which color?
Black.
White.
Light green.
Medium yellow.
Rationale
The color yellow is the easiest for a person with failing vision to see.
A client receiving cholestyramine (Questran) for hyperlipidemia should be
evaluated for what vitamin deficiency?
K.
B12.
B6.
C.
Rationale
This drug is administered to help lower the triglycerides levels. One of the side
effects clients should be monitored for an increased prothrombin time and
prolonged bleeding times which would alert the nurse to a vitamin K deficiency.
These drugs reduce absorption of the fat soluble (lipid) vitamins A, D, E, and K.
The nurse is caring for a client with a stroke resulting in right-sided paresis and
aphasia. The client attempts to use the left hand for feeding and other self-care
activities. The spouse becomes frustrated and insists on doing everything for
the client. Based on this data, which nursing diagnosis should the nurse
document for this client?
Situational low self-esteem related to functional impairment and change in
,role function.
, Disabled family coping related to dissonant coping style of
significant person. Interrupted family processes related to shift in
health status of family member.
Risk for ineffective therapeutic regimen management related to
complexity of care.
Rationale
A stroke affects the whole family and in this case the spouse probably thinks that
she is helping and needs to feel that she is contributing to the client's care. Her
help is noted as being incongruent with attempts of self-care by the client thereby
disabling family coping.
The nurse is interviewing a male client with hypertension. Which additional
medical diagnosis in the client's history presents the greatest risk for developing
a cerebral vascular accident (CVA)?
Diabetes
mellitus.
Hypothyroidism.
Parkinson's
disease. Recurring
pneumonia.
Rationale
According to the National Stroke Association (2013), history of diabetes mellitus
poses the greatest risk for developing a CVA, 2-4Xs more than those who do not
have diabetes mellitus. The reason for this occurrence is related to the excess
glucose circulating throughout the body not being utilizing by the cells of the
body, leading to the increased fatty deposits or clots inside the blood vessels in
the brain or neck, eventually causing a stroke.
In assessing a client diagnosed with primary hyperaldosteronism, the nurse
expects the laboratory test results to indicate a decreased serum level of which
substance?
Sodium.
Antidiuretic
hormone.
Potassium.
Glucose.
Rationale
Clients with primary hyperaldosteronism exhibit a profound decline in the serum
levels of potassium (hypokalemia). Hypertension, along with the hypokalemia are
the most prominent and universal signs for this condition. If both of these
findings are present, there is 50% likelihood the client to be diagnosed with
hyperaldosteronism.
Which intervention should the nurse implement for a female client diagnosed with
pelvic relaxation disorder?
, Describe proper administration of vaginal suppositories
and cream. Encourage the client to perform Kegel
exercises 10 times daily.
- Medical surgical (100% Verified)
Questions & Answers Latest Update.
The nurse is providing dietary instructions to a 68-year-old client who is at high
risk for development of coronary heart disease (CHD). Which information should
the nurse include?
Limit dietary selection of cholesterol to 300 mg per day.
Increase intake of soluble fiber to 10 to 25 grams per day.
Decrease plant stanols and sterols to less than 2
grams/day. Ensure saturated fat is less than 30% of
total caloric intake. Rationale
To reduce risk factors associated with coronary heart disease, the daily intake of
soluble fiber should be increased to between 10 and 25 gm. According to the
American Heart Association, soluble fibers help reduce the LDL cholesterol
levels.
Despite several eye surgeries, a 78-year-old client who lives alone has persistent
vision problems. The visiting nurse is discussing home safety hazards with the
client. The nurse suggests that the edges of the steps be painted which color?
Black.
White.
Light green.
Medium yellow.
Rationale
The color yellow is the easiest for a person with failing vision to see.
A client receiving cholestyramine (Questran) for hyperlipidemia should be
evaluated for what vitamin deficiency?
K.
B12.
B6.
C.
Rationale
This drug is administered to help lower the triglycerides levels. One of the side
effects clients should be monitored for an increased prothrombin time and
prolonged bleeding times which would alert the nurse to a vitamin K deficiency.
These drugs reduce absorption of the fat soluble (lipid) vitamins A, D, E, and K.
The nurse is caring for a client with a stroke resulting in right-sided paresis and
aphasia. The client attempts to use the left hand for feeding and other self-care
activities. The spouse becomes frustrated and insists on doing everything for
the client. Based on this data, which nursing diagnosis should the nurse
document for this client?
Situational low self-esteem related to functional impairment and change in
,role function.
, Disabled family coping related to dissonant coping style of
significant person. Interrupted family processes related to shift in
health status of family member.
Risk for ineffective therapeutic regimen management related to
complexity of care.
Rationale
A stroke affects the whole family and in this case the spouse probably thinks that
she is helping and needs to feel that she is contributing to the client's care. Her
help is noted as being incongruent with attempts of self-care by the client thereby
disabling family coping.
The nurse is interviewing a male client with hypertension. Which additional
medical diagnosis in the client's history presents the greatest risk for developing
a cerebral vascular accident (CVA)?
Diabetes
mellitus.
Hypothyroidism.
Parkinson's
disease. Recurring
pneumonia.
Rationale
According to the National Stroke Association (2013), history of diabetes mellitus
poses the greatest risk for developing a CVA, 2-4Xs more than those who do not
have diabetes mellitus. The reason for this occurrence is related to the excess
glucose circulating throughout the body not being utilizing by the cells of the
body, leading to the increased fatty deposits or clots inside the blood vessels in
the brain or neck, eventually causing a stroke.
In assessing a client diagnosed with primary hyperaldosteronism, the nurse
expects the laboratory test results to indicate a decreased serum level of which
substance?
Sodium.
Antidiuretic
hormone.
Potassium.
Glucose.
Rationale
Clients with primary hyperaldosteronism exhibit a profound decline in the serum
levels of potassium (hypokalemia). Hypertension, along with the hypokalemia are
the most prominent and universal signs for this condition. If both of these
findings are present, there is 50% likelihood the client to be diagnosed with
hyperaldosteronism.
Which intervention should the nurse implement for a female client diagnosed with
pelvic relaxation disorder?
, Describe proper administration of vaginal suppositories
and cream. Encourage the client to perform Kegel
exercises 10 times daily.
