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 C

Explanation

A. Obtain the client’s consent: It is not the nurse’s responsibility to obtain the client’s consent for a procedure. This responsibility lies with the healthcare provider performing the procedure.

B. Describe the consequences of forgoing treatment: While it’s important for the client to understand the consequences of not undergoing the procedure, it is the healthcare provider’s responsibility to explain these consequences, not the nurses.

C. Witness the client’s signature: This is correct. The nurse’s role in the informed consent process is to witness the client’s signature on the consent form and to verify that the client is consenting voluntarily and appears to be competent to do so.

D. Explain the risks and benefits of the procedure: While the nurse can reinforce information, it is the healthcare provider’s responsibility to explain the risks and benefits of the procedure. The nurse should ensure that the client understands the information provided by the healthcare provider

A. Determine the client's blood pressure 1 min after each position change. B. Place the client in a sitting position. C. Assist the client into a standing position. D. Check the blood pressure with the client in a supine position

Correct Answer is D

Explanation

(A) Determine the client’s blood pressure 1 min after each position change: While it’s important to check the client’s blood pressure after each position change when assessing for orthostatic hypotension, this is not the first step. The nurse should first establish a baseline blood pressure reading with the client in a supine position.

(B) Place the client in a sitting position: Although the nurse will eventually need to check the client’s blood pressure in a sitting position, the first step is to get a baseline reading with the client in a supine position.

(C) Assist the client into a standing position: The nurse will eventually assist the client into a standing position to check for changes in blood pressure, but this is not the first step. The initial step is to get a baseline reading with the client in a supine position.

(D) Check the blood pressure with the client in a supine position: This is the most appropriate first step. When checking for orthostatic hypotension, the nurse should first check the client’s blood pressure while they are lying flat (supine). This provides a baseline reading against which subsequent readings (taken when the client is sitting and standing) can be compared. If there’s a significant drop in blood pressure upon standing, this could indicate orthostatic hypotension.

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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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Naxlex Comprehensive Predictor Exams

A client is about to undergo an elective surgical procedure. Which of the following is the role of the nurse providing preoperative care regarding informed consent?

Correct Answer is C

Explanation

A nurse is collecting data on a client to check for orthostatic hypotension. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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