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Which instruction should the nurse provide a client who was recently diagnosed with Raynaud's disease?
- A. Avoid cold temperatures completely.
- B. Take medications only during flare-ups.
- C. Wear gloves when removing packages from the freezer.
- D. Limit physical activity to avoid stress.
Correct Answer: C
Rationale: The correct instruction for a client with Raynaud's disease is to wear gloves when handling cold items to prevent vasospasm. Raynaud's disease is characterized by vasospasm in response to cold or stress, leading to reduced blood flow to extremities. Wearing gloves when removing packages from the freezer helps minimize exposure to cold temperatures and can prevent triggering vasospasms. Choices A, B, and D are incorrect. Avoiding cold temperatures completely is impractical and may not always be possible. Taking medications only during flare-ups does not address prevention strategies, and limiting physical activity to avoid stress is not a primary intervention for Raynaud's disease.
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Recurrent abdominal pain (RAP) is most often seen in school-age or adolescent children. The nurse should assess closely for what potential problem?
- A. Physical problems
- B. Relational problems
- C. Eating disorders
- D. Emotional problems
Correct Answer: D
Rationale: The correct answer is D: 'Emotional problems.' Recurrent abdominal pain (RAP) in children is frequently associated with emotional factors rather than physical issues, relational problems, or eating disorders. Children may manifest emotional distress through physical symptoms like abdominal pain, making it crucial for nurses to assess for emotional problems as a potential cause.
An older adult with chronic obstructive pulmonary disease (COPD) was recently admitted to the hospital with heart failure (HF). Which actions should the nurse take in providing care? (Select all that apply)
- A. Monitor electrolyte levels.
- B. Maintain pulse oximetry.
- C. Provide assistance with mobility.
- D. All of the Above
Correct Answer: D
Rationale: In a patient with COPD and HF, monitoring electrolyte levels is essential due to potential imbalances caused by medications or fluid shifts. Maintaining pulse oximetry is crucial to assess oxygenation status in COPD and HF. Providing assistance with mobility helps prevent deconditioning and complications. Therefore, all the actions mentioned are necessary for comprehensive care in this scenario, making option D the correct answer. Choices A, B, and C are all important aspects of managing COPD and HF, ensuring holistic and effective care.
What is the most common clinical manifestation of coarctation of the aorta?
- A. Clubbing of the digits
- B. Upper extremity hypertension
- C. Pedal edema and portal congestion
- D. Loud systolic ejection murmur
Correct Answer: B
Rationale: The correct answer is B: Upper extremity hypertension. Coarctation of the aorta leads to increased blood pressure in the upper extremities. The pressure in the arms is typically 20 mm Hg higher than in the legs. Choice A, clubbing of the digits, is not a common clinical manifestation of coarctation of the aorta. Choice C, pedal edema, and portal congestion are more suggestive of conditions like heart failure rather than coarctation of the aorta. Choice D, loud systolic ejection murmur, can be heard in conditions like aortic stenosis, but it is not the most common clinical manifestation of coarctation of the aorta.
An older female client has normal saline infusing at 45 ml/hour. She complains of pain at the insertion of the IV catheter. There is no redness or edema around the IV site. Which action should the nurse take?
- A. Determine what IV medications have recently been administered.
- B. Slow the infusion rate.
- C. Apply a warm compress to the IV site.
- D. Discontinue the IV line and start a new one.
Correct Answer: A
Rationale: The correct action for the nurse to take in this scenario is to determine what IV medications have recently been administered. This is important to identify if the pain at the IV site is related to a medication infusion. Slowing the infusion rate (choice B) may not address the underlying cause of the pain. Applying a warm compress (choice C) is not necessary since there is no redness or edema around the IV site. Discontinuing the IV line and starting a new one (choice D) is a drastic step and should not be the first action taken without investigating the cause of the pain.
During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?
- A. An old friend with eczema came for a visit.
- B. Recently received an influenza immunization.
- C. A grandson and his new dog recently visited.
- D. Corticosteroid cream was applied to eczema.
Correct Answer: C
Rationale: The correct answer is C. Contact with the grandson's new dog could have introduced new allergens or irritants, exacerbating the eczema symptoms. Choice A is unrelated to the exacerbation of symptoms. Choice B, receiving an influenza immunization, is unlikely to directly cause an exacerbation of eczema symptoms. Choice D, applying corticosteroid cream, is a common treatment for eczema and would not likely be the cause of the exacerbation.