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 C
Explanation
Rationale:
A. "I will remove my shoes when I'm inside my house.": While keeping the environment safe from tripping hazards is good for general safety, removing shoes does not specifically prevent bleeding, which is the main concern in thrombocytopenia. This action does not demonstrate understanding of bleeding precautions.
B. "I will floss between my teeth every time I brush": Flossing can cause gum bleeding, which is risky for clients with low platelet counts. Effective teaching would emphasize avoiding activities that may cause mucosal or skin bleeding, so this statement reflects a misunderstanding.
C. "I will wipe my nose instead of blowing it.": Gentle wiping reduces the risk of nasal bleeding, which is important in clients with thrombocytopenia. This statement shows the client understands the need to minimize trauma to areas prone to bleeding and demonstrates correct application of bleeding precautions.
D. "I will use an enema to manage my constipation.": Using an enema can cause mucosal trauma and rectal bleeding, which is unsafe for clients with thrombocytopenia. Safe constipation management would involve gentle measures such as stool softeners and increased hydration.
Correct Answer is D
Explanation
Rationale:
A. "Store oxygen cylinders on their side.": Oxygen cylinders should always be stored upright and secured to prevent tipping, rolling, or falling, which could damage the valve and create a fire hazard. Storing cylinders on their side increases the risk of accidents and is unsafe in the home setting.
B. "Use two-prong electrical outlets in the room where oxygen is used.": Electrical safety requires that outlets and devices used near oxygen be in good condition and free of sparks. The number of prongs is not the key concern; rather, all electrical equipment should be properly grounded and well-maintained to prevent ignition in an oxygen-rich environment.
C. "You can adjust the flow of your oxygen as needed.": Oxygen flow should only be adjusted according to the provider’s prescription. Changing the flow without guidance can result in hypoxia if decreased or oxygen toxicity if increased, making this statement unsafe and incorrect.
D. "Notify your power company that oxygen is used in the home.": Informing the power company is an important safety measure because home oxygen use increases fire risk. Utility companies can provide guidance on electrical safety, and emergency responders will be aware of the presence of oxygen in case of power outages or accidents.
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