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A client seeks medical attention for intermittent signs and symptoms that suggest a diagnosis of Raynaud’s disease. The nurse should assess the trigger of these signs/symptoms by asking which?
- A. Does drinking coffee or ingesting chocolate seem related to the episodes?
- B. Does being exposed to heat seem to cause the episodes?
- C. Do the signs and symptoms occur while you are asleep?
- D. Have you experienced any injuries that have limited your activity levels lately?
Correct Answer: A
Rationale: The correct answer is A: Does drinking coffee or ingesting chocolate seem related to the episodes? This question is relevant because caffeine and chocolate are known triggers for Raynaud's disease due to their vasoconstrictive properties. By asking about these specific triggers, the nurse can gather important information to help identify potential causes of the client's symptoms.
Choice B is incorrect because exposure to heat typically alleviates symptoms of Raynaud's disease rather than causing them. Choice C is irrelevant as Raynaud's symptoms typically occur when the individual is exposed to cold or experiencing stress, not while asleep. Choice D is also incorrect as injuries limiting activity levels are not directly related to Raynaud's disease triggers.
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A client diagnosed with diverticulitis has been experiencing episodes of gastrointestinal cramping. The nurse should tell the client to maintain which type of diet during the asymptomatic period?
- A. High in carbohydrates.
- B. High in fiber.
- C. Low in residue.
- D. Low in fat.
Correct Answer: B
Rationale: The correct answer is B: High in fiber. During the asymptomatic period of diverticulitis, a high-fiber diet helps prevent diverticula formation and reduces the risk of diverticulitis flare-ups by promoting regular bowel movements and preventing constipation. Fiber also helps maintain healthy gut flora. Choices A, C, and D are incorrect as high carbohydrates may worsen symptoms, low residue may lead to constipation, and low fat is not directly related to diverticulitis management.
A nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site?
- A. The area surrounding the insertion site feels warm to the touch.
- B. The infusion rate has stopped but the tubing is not kinked.
- C. There is fluid leaking around the insertion site.
- D. There is no blood return when the tubing is aspirated.
Correct Answer: A
Rationale: The correct answer is A because warmth at the insertion site is a classic sign of phlebitis, indicating inflammation of the vein. This is due to irritation from the IV catheter. Choice B is incorrect because the infusion rate stopping is not specific to phlebitis. Choice C is incorrect as fluid leaking suggests an issue with the dressing or the catheter. Choice D is incorrect as no blood return could indicate a clot but not necessarily phlebitis.
A nurse in the outpatient clinic is assessing a client who has psoriasis. The nurse should expect which of the following findings?
- A. Silvery, white scales.
- B. Intense pain.
- C. Unilateral lesions.
- D. Serous drainage.
Correct Answer: A
Rationale: The correct answer is A: Silvery, white scales. Psoriasis is characterized by the presence of silvery, white scales on the skin due to rapid skin cell turnover. This finding is classic for psoriasis. Intense pain (B) is not a typical symptom of psoriasis; it is more commonly associated with conditions like shingles. Unilateral lesions (C) would not be expected in psoriasis, as it often affects both sides of the body symmetrically. Serous drainage (D) is not a typical feature of psoriasis, which primarily presents with dry, scaly patches.
A nurse is providing teaching to a group of clients. Which of the following clients is at risk for developing peripheral arterial disease?
- A. A client whose daily caloric intake is 25% fat.
- B. A client who has diabetes mellitus.
- C. A client who consumes two 12-ounce (0.35-L) alcoholic beverages daily.
- D. A client who has hypothyroidism.
Correct Answer: B
Rationale: The correct answer is B: A client who has diabetes mellitus. Diabetes mellitus is a major risk factor for developing peripheral arterial disease (PAD) due to atherosclerosis caused by high blood sugar levels damaging blood vessels over time. This leads to reduced blood flow to the extremities, increasing the risk of PAD.
Choice A is incorrect as fat intake alone does not directly correlate with PAD development. Choice C is incorrect as moderate alcohol consumption is not a significant risk factor for PAD. Choice D is incorrect as hypothyroidism is not a primary risk factor for PAD. It is essential to focus on diabetes management and lifestyle modifications to reduce the risk of developing PAD in clients with diabetes mellitus.
A nurse is caring for a client who is cognitively impaired and repeatedly pulls on his NG tube. Which of the following actions should the nurse take before requesting a prescription for restraints? (Select all that apply.)
- A. Provide diversionary activities for the client.
- B. Assist the client with toileting at frequent intervals.
- C. Involve the family in the client’s care.
- D. Explain to the client that he will be restrained if he does not stop pulling on his NG tube.
- E. Use an electronic bed alarm device.
Correct Answer: A,B,C,E
Rationale: The correct actions are A, B, C, and E. A) Providing diversionary activities can distract the client from pulling on the NG tube. B) Assisting with toileting at frequent intervals helps address any discomfort or restlessness that may be contributing to the behavior. C) Involving the family can provide additional support and understanding of the client's needs. E) Using an electronic bed alarm device can alert the nurse when the client is attempting to pull on the NG tube, allowing for timely intervention. These actions focus on addressing the underlying reasons for the behavior and ensuring the client's safety without resorting to restraints, which should be a last resort due to ethical and legal considerations.