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. Peripheral edema is present: Peripheral edema indicates fluid overload rather than restored fluid balance. Excess interstitial fluid reflects that the body has retained more fluid than necessary, which is a sign that fluid status is not yet normalized.
B. Crackles upon auscultation of the lungs: Lung crackles suggest pulmonary congestion, which is a sign of fluid overload. This finding indicates that fluid replacement may have exceeded the client’s needs, so fluid balance has not been restored appropriately.
C. Maternal heart rate is 110/min: Tachycardia can indicate ongoing hypovolemia or stress on the cardiovascular system. A normalized fluid balance would typically correspond with a heart rate within the client’s baseline range, generally around 60–100/min, rather than persistent tachycardia.
D. Urine output for 1 hour is 35 mL: Adequate urine output (generally ≥30 mL/hr for adults) indicates effective renal perfusion and suggests that intravascular volume has been restored. This is a key clinical indicator of fluid balance normalization following hemorrhage and fluid replacement.
Correct Answer is ["200"]
Explanation
Answer: 200 mL/hr
Calculation:
- Identify the total volume to be infused and the infusion time
Total Volume: 200 mL
Infusion Time: 60 minutes (1 hour)
- Calculate the infusion rate
Infusion Rate (mL/hr) = Total Volume ÷ Time (hr)
Infusion Rate = 200 ÷ 1
Infusion Rate = 200 mL/hr
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