A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Which of the following client statements should indicate to the nurse the need for additional teaching?

"I will wear gloves when removing food from the freezer"

"I will take my medications at the first sign of an attack"

"I will try to anticipate and avoid stressful situations when possible"

"I will complete the smoking cessation program I started"

Answer and Explanation

The Correct Answer is B

A. "I will wear gloves when removing food from the freezer": This statement demonstrates understanding of the need to protect the hands from cold exposure, which can trigger Raynaud's disease symptoms. Wearing gloves when handling cold objects, such as food from the freezer, helps minimize the risk of a vasospastic episode.
B. "I will take my medications at the first sign of an attack": This statement indicates a misunderstanding of the appropriate use of medications for Raynaud's disease. While medications such as calcium channel blockers may be prescribed to prevent or reduce the frequency and severity of attacks, they are typically taken regularly as part of ongoing management rather than at the first sign of symptoms. This client may need additional education on the proper use of medications for Raynaud's disease.
C. "I will try to anticipate and avoid stressful situations when possible": Stress can exacerbate symptoms of Raynaud's disease by triggering vasospasm, so anticipating and avoiding stressful situations is a proactive strategy to help prevent attacks. This statement reflects an understanding of the importance of stress management in managing the condition.
D. "I will complete the smoking cessation program I started": Smoking is a significant risk factor for Raynaud's disease and can worsen symptoms by constricting blood vessels. Committing to a smoking cessation program demonstrates the client's recognition of the importance of lifestyle modifications in managing the condition.

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Correct Answer is A, C, B, D, E

Explanation

A. Open the airway using a jaw-thrust maneuver: The first step in a primary survey is to assess the airway and ensure it is open. The jaw-thrust maneuver is used to open the airway without moving the neck in case of a potential cervical spine injury.

C. Determine effectiveness of ventilator efforts: Once the airway is open, the next step is to assess breathing. This includes observing for chest rise and fall, listening for breath sounds, and feeling for air movement.

B. Establish IV access: After the airway and breathing have been assessed, circulation is the next priority. This includes establishing IV access for fluid and medication administration.

D. Perform a Glasgow Coma Scale assessment: The Glasgow Coma Scale is used to assess the client’s level of consciousness, which is part of the disability assessment in the primary survey.

E. Remove clothing for a thorough assessment: Finally, removing the client’s clothing allows for a thorough assessment of injuries. This is typically done after the immediate life-threatening issues have been addressed.

A. Delayed gastric emptying B. Pulmonary edema C. An upper respiratory infection D. Atelectasis

Correct Answer is D

Explanation

A. Delayed gastric emptying is not associated with decreased breath sounds in the lower lobes of the lungs. It is more commonly associated with gastrointestinal symptoms such as bloating and nausea.
B. While pulmonary edema can cause respiratory symptoms, such as crackles and wheezes, decreased breath sounds in the lower lobes are not typically indicative of pulmonary edema. Pulmonary edema is more commonly associated with fluid accumulation in the lungs, leading to crackles and other signs of fluid overload.
C. An upper respiratory infection primarily affects the upper airways, such as the nose and throat, and typically presents with symptoms such as nasal congestion, sore throat, and cough. It is not typically associated with decreased breath sounds in the lower lobes of the lungs.
D. Atelectasis refers to the collapse or closure of a part of the lung, leading to decreased air entry and breath sounds in the affected area. In a client who has been on bedrest for several days, atelectasis can occur due to reduced lung expansion and ventilation. Decreased breath sounds in the lower lobes are a common finding in atelectasis, especially when the condition affects the bases of the lungs, as gravitational forces can exacerbate the collapse of lung tissue in dependent areas. Therefore, this finding is most consistent with atelectasis.

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A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Which of the following client statements should indicate to the nurse the need for additional teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is conducting a primary survey of a client who has sustained life threatening injuries due to a motor vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.)

Correct Answer is A, C, B, D, E

Explanation

A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions?

Correct Answer is D

Explanation

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