A nurse is taking an admission history from a client who reports Raynaud's disease. Which of the following assessment findings should the nurse identify as a potential trigger for exacerbations of Raynaud's?
A history of herpes zoster
Taking amlodipine for hypertension
Using a nicotine transdermal patch
Eating a strict vegetarian diet
The Correct Answer is C
C. Nicotine is a vasoconstrictor, meaning it causes narrowing of blood vessels. Therefore, using a nicotine transdermal patch can exacerbate Raynaud's attacks by promoting vasoconstriction and reducing blood flow to the extremities.
A. While herpes zoster (shingles) is a viral infection caused by the varicella-zoster virus, it is not directly associated with triggering Raynaud's attacks.
B. Amlodipine is a calcium channel blocker medication commonly used to treat hypertension.
D. While diet can potentially influence overall health and vascular function, there is no direct evidence to suggest that a strict vegetarian diet would trigger exacerbations of Raynaud's disease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Turning the client on their side helps prevent aspiration (inhaling fluid or vomit into the lungs) and promotes drainage of oral secretions, reducing the risk of airway obstruction during the seizure.
B. While assessing neurological status is important, it should be done after ensuring the client's safety during the seizure. This can be done after the seizure has stopped.
C. While obtaining vital signs is important for assessing the client's overall condition, it is not the immediate priority during an active seizure. Vital signs can be assessed once the seizure has stopped and the client's safety has been ensured.
D. Notifying the rapid response team may be necessary if the seizure persists beyond a certain duration (status epilepticus) or if there are complications. However, the first action should be to ensure the client's immediate safety by turning them onto their side to prevent aspiration.
Correct Answer is C
Explanation
A. Bladder spasms are a common postoperative complication after TURP, and they are typically associated with the irritation of the bladder wall. Cold compresses may be helpful for reducing muscle spasms or swelling in other situations, but they are not typically effective for relieving bladder spasms specifically.
B. Securing the urinary catheter is important to prevent dislodgement and ensure proper drainage. However, securing it to the upper left quadrant of the abdomen is not a standard practice.
C. The appropriate response is often to irrigate the catheter to relieve the obstruction and restore normal flow. While 0.9% sodium chloride (normal saline) is typically used for irrigation, the term "intermittent" refers to manually irrigating the catheter at intervals to flush out any blockages, which is an appropriate approach when there is a concern about obstruction.
D. Encouraging the client to urinate every 2 hours is not feasible or necessary in this situation.
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