Nokea
In order to prevent recurrent vasospastic episodes with Raynaud's phenomenon, the nurse should instruct the client to:
- A. Keep the hands and feet elevated as much as possible
- B. Use a vibrating massage device on the hands
- C. Wear gloves when obtaining food from the refrigerator
- D. Increase coffee intake to 2 cups per day
Correct Answer: C
Rationale: Wearing gloves when obtaining food from the refrigerator prevents cold-triggered vasospasm in Raynaud's. Elevation is irrelevant, vibrating devices may worsen symptoms, and coffee (caffeine) can cause vasoconstriction, increasing episodes.
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When assessing the lower extremities of a client with peripheral vascular disease (PVD), the nurse notes bilateral ankle edema. The edema is related to:
- A. Decreased blood volume
- B. Increase in muscular activity
- C. Increased venous pressure
- D. Increased arterial pressure
Correct Answer: C
Rationale: Bilateral ankle edema in PVD is often due to increased venous pressure from venous insufficiency or right-sided heart failure, which impairs venous return and causes fluid to pool in the lower extremities. Decreased blood volume or increased muscular activity does not cause edema, and arterial pressure is not directly related.
A client with macrocytic anemia has a burn on her foot and states that she had been watching television while lying on a heating pad. Which action should be the nurse's first response?
- A. Assess for potential abuse.
- B. Check for diminished sensations.
- C. Document the findings.
- D. Clean and dress the area.
Correct Answer: B
Rationale: Macrocytic anemia, often due to vitamin B12 or folate deficiency, can cause peripheral neuropathy, leading to diminished sensations and increased risk of burns from prolonged heat exposure. The nurse's first action should be to check for sensory deficits to assess the underlying cause of the injury. Assessing for abuse, documenting, or dressing the wound are secondary actions.
A client with an ileal conduit reports skin irritation around the stoma. What should the nurse recommend?
- A. Apply a skin barrier cream.
- B. Use adhesive tape to secure the appliance.
- C. Clean the area with alcohol.
- D. Change the appliance daily.
Correct Answer: A
Rationale: A skin barrier cream protects the peristomal skin from urine irritation, promoting healing and preventing further breakdown.
The client who has been hospitalized with pancreatitis does not drink alcohol because of her religious convictions. She becomes upset when the physician persists in asking her about alcohol intake. The nurse should explain that the reason for these questions is that:
- A. There is a strong link between alcohol use and acute pancreatitis.
- B. Alcohol intake can interfere with the tests used to diagnose pancreatitis.
- C. Alcoholism is a major health problem, and all clients are questioned about alcohol intake.
- D. The physician must obtain the pertinent facts, regardless of religious beliefs.
Correct Answer: A
Rationale: Alcohol is a primary cause of acute pancreatitis, so questioning its use (A) is essential to identify etiology. Interference with tests (B), general alcoholism screening (C), or disregarding beliefs (D) are not accurate explanations.
A client post-cystoscopy is discharged. The nurse should instruct to:
- A. Resume normal activity.
- B. Avoid fluids for 24 hours.
- C. Expect blue urine.
- D. Take antibiotics for a week.
Correct Answer: A
Rationale: Normal activity can resume post-cystoscopy unless complications arise.