A nurse is caring for a client who has Raynaud's disease. Which of the following actions should the nurse take?
Provide information about stress management.
Administer epinephrine for acute episodes.
Maintain a cool temperature in the client's room.
Give a glucocorticoid steroid twice per day.
The Correct Answer is A
Rationale:
A. Provide information about stress management.: Stress is a major trigger for vasospastic episodes in Raynaud’s disease because it increases sympathetic nervous system activity, causing further arterial constriction. Stress-reduction techniques such as deep breathing, biofeedback, or relaxation exercises helps reduce the frequency and severity of attacks.
B. Administer epinephrine for acute episodes.: Epinephrine causes vasoconstriction, which would worsen Raynaud’s symptoms by further reducing blood flow to the extremities. During an acute episode, warming the affected areas and avoiding additional vasoconstrictors is essential. Epinephrine is not indicated as a treatment and can intensify ischemic discomfort
C. Maintain a cool temperature in the client's room.: Cold temperatures are one of the most common triggers for vasospasm in Raynaud’s disease. A cool environment increase the likelihood of an episode by promoting peripheral vasoconstriction. The nurse should provide a warm environment and encourage protective clothing to maintain circulation.
D. Give a glucocorticoid steroid twice per day.: Steroids are not a standard treatment for Raynaud’s because the condition is related to vasospasm rather than inflammatory processes. Routine steroid use would expose the client to unnecessary adverse effects without addressing the underlying problem. Management strategies focus instead on warmth, lifestyle modification, and vasodilator medications when needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Instruct the client to carry the newborn in their arms when going to the nursery: Carrying a newborn to the nursery without security measures increases the risk of abduction. Infants should always be transported in a secure bassinet or by authorized staff using the hospital’s safety protocols.
B. Remove the electronic security sensor when the newborn is in the client's room: The electronic security sensor is essential for monitoring the newborn’s location within the hospital. Removing it defeats the purpose of the abduction prevention system and is unsafe.
C. Apply identification bands after the newborn's first bath: Identification bands should be applied immediately after birth to ensure accurate identification from the start. Waiting until after the first bath delays verification and increases risk for misidentification or abduction.
D. Discourage family from posting photos of the newborn on social media: Sharing identifiable information or images online can inadvertently alert potential abductors to the newborn’s presence. Families should be advised to limit social media exposure until the infant’s safety can be ensured.
Correct Answer is D
Explanation
Rationale:
A. Place an ice pack directly on the skin of the affected joints: Ice should never be applied directly to the skin as it can cause frostbite or skin damage. It should be wrapped in a cloth or towel before use. While cold therapy can reduce inflammation and numb pain, safety precautions are essential.
B. Limit dietary intake of phosphorus: Phosphorus restriction is not relevant for osteoarthritis management. Dietary modifications for osteoarthritis focus more on maintaining a healthy weight and anti-inflammatory nutrients rather than phosphorus intake.
C. Place a large pillow under the knees when sleeping: Placing a large pillow under the knees can hyperflex the joints and increase strain on the knees and hips. Proper positioning involves keeping joints in a neutral or slightly extended position to reduce discomfort and prevent contractures.
D. Take a hot shower every day: Heat therapy helps relax muscles, relieve stiffness, and improve joint mobility in clients with osteoarthritis. Warm showers or moist heat applications are effective nonpharmacological interventions for managing pain and promoting comfort.
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