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 B
Explanation
Rationale:
A. "What questions do you have about reading food labels?": This question assesses nutrition literacy rather than dietary acculturation. It focuses on understanding nutritional information, not cultural food practices or adaptations.
B. "Do you have special customs that you follow for meals?": This question directly addresses dietary acculturation by exploring cultural or traditional food practices and meal patterns. It helps the nurse understand how the client’s cultural background influences their diet and eating behaviors.
C. "Are there any foods that you are allergic to?": This question assesses food safety and potential allergens, not cultural or acculturation aspects of the diet.
D. "How do you feel about your current body weight?": This question addresses body image and personal perception, which may influence dietary choices but does not provide information about cultural or acculturation influences on diet.
Correct Answer is C
Explanation
Rationale:
A. "I will provide my child with high-fiber foods": While fiber is important for overall health, many high-fiber grains contain gluten, which must be avoided in celiac disease. Offering high-fiber foods without confirming they are gluten-free could cause intestinal damage and symptoms in the child.
B. "I will give my child whole wheat toast and milk for breakfast": Whole wheat contains gluten, which triggers an autoimmune response in children with celiac disease. Serving whole wheat toast is unsafe and indicates a misunderstanding of dietary restrictions for managing this condition.
C. "I will keep my child on a gluten-free diet": A strict gluten-free diet is the primary treatment for celiac disease. Eliminating all sources of wheat, barley, rye, and derivatives allows intestinal healing, prevents symptoms, and reduces the risk of long-term complications, showing correct understanding of dietary management.
D. "I will administer digestive enzymes with meals and snacks.": Digestive enzymes are not a standard treatment for celiac disease and do not prevent the autoimmune response caused by gluten. The focus should remain on dietary avoidance of gluten rather than relying on enzyme supplementation.
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