A nurse is reinforcing teaching with a client about how to prevent the onset of manifestations of Raynaud's phenomenon. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

"I will try to anticipate and avoid stressful situations."

"I will keep my house at a cool temperature."

"I will complete the smoking cessation program I started."

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

Answer and Explanation

The Correct Answer is B

B) "I will keep my house at a cool temperature": This statement indicates a need for further teaching because maintaining a warm environment is recommended for individuals with Raynaud's phenomenon to prevent vasoconstriction and reduce the risk of attacks. Cold temperatures can trigger symptoms in individuals with this condition. Therefore, advising the client to keep their house warm is appropriate and aligns with preventive measures for Raynaud's phenomenon.

A) "I will try to anticipate and avoid stressful situations": Stress management is an essential aspect of managing Raynaud's phenomenon, as stress can trigger vasospasms. Anticipating and avoiding stressful situations can help reduce the frequency and severity of symptoms.

C) "I will complete the smoking cessation program I started": Smoking cessation is crucial for individuals with Raynaud's phenomenon because smoking narrows blood vessels and exacerbates symptoms. Completing a smoking cessation program is a positive step toward reducing the risk of vasospasms.

D) "I will wear gloves when removing food from the freezer": Wearing gloves when handling cold objects, such as food from the freezer, is recommended for individuals with Raynaud's phenomenon to prevent triggering attacks due to exposure to cold temperatures. This statement demonstrates an understanding of preventive measures for managing the condition.

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Correct Answer is A

Explanation

A) Recent oral intake: This information is crucial because pyridostigmine is typically administered orally and can interact with food, affecting its absorption. Ensuring that the client has recently eaten or will eat soon is essential to minimize gastrointestinal side effects and optimize medication absorption.

B) Trouble sleeping: While sleep disturbances can be a concern, particularly if they worsen with medication use, they may not be the most critical information to obtain before administering pyridostigmine. However, if the client experiences worsening sleep disturbances after starting the medication, it should be reported to the healthcare provider.

C) Unexplained weight loss: While weight loss can be a symptom of myasthenia gravis, it may not be directly related to the administration of pyridostigmine. However, if the client experiences significant weight loss or other unexplained symptoms, further assessment and evaluation may be necessary.

D) Difficulty with urination: Pyridostigmine can affect bladder function and may exacerbate urinary retention, especially in clients with myasthenia gravis. However, obtaining information about the client's recent oral intake is more crucial to ensure optimal medication absorption and minimize gastrointestinal side effects. Difficulty with urination should still be monitored, but it may not be the most immediate concern before administering the medication.

A. Heart rate of 66/min B. BP of 148/94 mm Hg C. Peripheral edema of the ankles D. A digoxin level of 1.2 ng/mL.

Correct Answer is C

Explanation

(a) Heart rate of 66/min:
A heart rate of 66/min is within the normal range (60-100 bpm) and does not typically require contacting the provider before administering a calcium channel blocker. CCBs can affect heart rate, but this finding alone is not a contraindication for their use.

(b) BP of 148/94 mm Hg:
A blood pressure reading of 148/94 mm Hg indicates hypertension, which is an appropriate indication for the use of calcium channel blockers. This finding supports the use of the medication rather than requiring the provider to be contacted.

(c) Peripheral edema of the ankles:
Peripheral edema is a known side effect of calcium channel blockers. If the client is already experiencing edema, administering the medication could potentially worsen this condition. The nurse should contact the provider to discuss this finding before proceeding with the medication administration.

(d) A digoxin level of 1.2 ng/mL:
A digoxin level of 1.2 ng/mL is within the therapeutic range (0.5-2.0 ng/mL). This finding does not necessitate contacting the provider before administering a calcium channel blocker, as it does not indicate toxicity or a contraindication for CCB use

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A nurse is reinforcing teaching with a client about how to prevent the onset of manifestations of Raynaud's phenomenon. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

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Correct Answer is A

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