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The nurse is obtaining a focused interview. Which statements made by the client suggest that the client has an increased risk of developing cardiovascular disease? Select all that apply.

"I have cut back on fat and switched to a vegetarian diet."

"I have cut back on my smoking."

"I have been stressed out since my divorce last year."

"I have an occasional glass of wine."

"I have gained 25 pounds over the past year.

Question Solution

Correct Answer : C,E

A) "I have cut back on fat and switched to a vegetarian diet." This statement suggests a positive change in dietary habits, which can lower the risk of cardiovascular disease. A vegetarian diet, particularly if it includes plenty of fruits, vegetables, and whole grains, is associated with a reduced risk of heart disease. Therefore, this statement does not indicate an increased risk.

B) "I have cut back on my smoking." While reducing smoking is a positive step, smoking itself is a significant risk factor for cardiovascular disease. However, the statement indicates an attempt to decrease risk, which does not inherently suggest an increased risk. It may show improvement rather than risk.

C) "I have been stressed out since my divorce last year." Chronic stress is a recognized risk factor for cardiovascular disease, as it can lead to behaviors such as poor diet, inactivity, and increased blood pressure. This statement highlights a significant concern for the client’s cardiovascular health.

D) "I have an occasional glass of wine." Moderate alcohol consumption is sometimes associated with cardiovascular benefits. While excessive drinking can pose risks, this statement alone does not indicate an increased risk of cardiovascular disease. It reflects moderation rather than concern.

E) "I have gained 25 pounds over the past year." Weight gain, especially if it leads to obesity, is a significant risk factor for developing cardiovascular disease. This statement indicates a change in health status that could negatively impact the client’s cardiovascular risk profile.

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A. This would indicate pitting edema B. This may indicate dehydration, but might not be reliable in an older adult C. This means the client is well hydrated D. This indicates peripheral neuropathy

Correct Answer is B

Explanation

A) This would indicate pitting edema: Tenting is not indicative of pitting edema, which is characterized by a depression left in the skin after pressure is applied. Tenting specifically refers to the skin's elasticity and is assessed by pinching the skin, observing how quickly it returns to its normal position.

B) This may indicate dehydration, but might not be reliable in an older adult: Tenting is often a sign of dehydration, as it reflects decreased skin elasticity. However, in elderly individuals, skin changes due to aging (like reduced elasticity and moisture) may make this assessment less reliable. Factors such as medications, health status, and overall skin integrity can also influence this observation, making it necessary to consider other indicators of hydration.

C) This means the client is well hydrated: Tenting does not indicate adequate hydration. In fact, it typically suggests the opposite, as well-hydrated skin should return to normal quickly after being pinched.

D) This indicates peripheral neuropathy: While peripheral neuropathy can affect skin and tissue integrity, tenting specifically relates to skin turgor and elasticity rather than nerve function. Tenting is not a direct indicator of neuropathy; other assessments would be needed to evaluate nerve health.

A. Left extremity cool to touch, normal pitting edema, with femoral, posterior tibial, and dorsalis pedis pulses palpable, +2. B. Left lower extremity cool to touch, +2 pitting edema, with femoral, popliteal, and dorsalis pedis pulses palpable, +2. C. Left lower leg cool to touch, +4 edema with femoral, posterial tibial, dorsalis and pedis pulses normal. D. Left lower leg normal cool temperature, slight swelling, femoral, posterior tibial and dorsalis pedis pulses normal.

Correct Answer is B

Explanation

A) Left extremity cool to touch, normal pitting edema, with femoral, posterior tibial, and dorsalis pedis pulses palpable, +2: While this option describes the left extremity and includes some relevant details, it inaccurately uses "normal pitting edema" without specifying the degree of edema clearly. Additionally, it lists the posterior tibial pulse instead of the popliteal, which is more appropriate given the anatomical location.

B) Left lower extremity cool to touch, +2 pitting edema, with femoral, popliteal, and dorsalis pedis pulses palpable, +2: This documentation accurately describes the left lower extremity, specifies the degree of edema as "+2," and correctly identifies the relevant pulses as femoral, popliteal, and dorsalis pedis. This terminology is clear and concise, providing a comprehensive assessment of the vascular status.

C) Left lower leg cool to touch, +4 edema with femoral, posterial tibial, dorsalis and pedis pulses normal: This option incorrectly reports the degree of edema as "+4," which indicates severe swelling, not matching the original assessment of "mild edema." It also incorrectly lists the posterior tibial pulse, which should be popliteal.

D) Left lower leg normal cool temperature, slight swelling, femoral, posterior tibial and dorsalis pedis pulses normal: The term "normal cool temperature" is confusing and not standard terminology. Additionally, "slight swelling" lacks specificity regarding the degree of edema, which is important for a clinical assessment. Furthermore, it inaccurately refers to the posterior tibial pulse instead of the popliteal.

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The nurse is obtaining a focused interview. Which statements made by the client suggest that the client has an increased risk of developing cardiovascular disease? Select all that apply.

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Correct Answer is B

Explanation

Correct Answer is B

Explanation

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Take full exam for free The nurse is obtaining a focused interview. Which statements made by the client suggest that the client has an increased risk of developing cardiovascular disease? Select all that apply.

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When assessing the skin of an elderly client, the nurse notes tenting. The nurse understands what about this assessment?

Correct Answer is B

Explanation

A student nurse documents the following: Lower left leg cool, mild edema, with dorsalis pedis, posterior knee and femoral pulse normal. How should this documentation be charted to communicate the assessment using appropriate medical terminology?

Correct Answer is B

Explanation

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The nurse is obtaining a focused interview. Which statements made by the client suggest that the client has an increased risk of developing cardiovascular disease? Select all that apply.