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?

“Does drinking coffee or ingesting chocolate seem related to the episodes?”

“Does being exposed to heat seem to cause the episodes?”

“Do the signs and symptoms occur while you are asleep?”

“Have you experienced any injuries that have limited your activity levels lately?”

Answer and Explanation

The Correct Answer is A

Choice A rationale

Drinking coffee or ingesting chocolate can trigger Raynaud’s disease symptoms. Both caffeine and chocolate can cause vasoconstriction, which can exacerbate the symptoms of Raynaud’s disease.

Choice B rationale

Being exposed to heat is not a common trigger for Raynaud’s disease. The condition is typically triggered by cold temperatures or stress.

Choice C rationale

Symptoms of Raynaud’s disease do not typically occur while asleep. The condition is more likely to be triggered by cold or stress during waking hours.

Choice D rationale

Injuries that limit activity levels are not directly related to the triggers of Raynaud’s disease. The primary triggers are cold temperatures and stress.

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Correct Answer is C

Explanation

Choice A rationale

Inserting a nasogastric (NG) tube is not the first priority in managing a client with gastrointestinal bleeding. The primary concern is to stabilize the client and assess their condition. Inserting an NG tube can be considered later to decompress the stomach and assess the extent of bleeding, but it is not the initial step.

Choice B rationale

Asking the client about the precipitating events is important for gathering information, but it is not the first priority. The immediate focus should be on assessing the client’s current condition and stabilizing them. Once the client is stable, a detailed history can be obtained.

Choice C rationale

Obtaining vital signs is the first priority in managing a client with gastrointestinal bleeding. Vital signs provide critical information about the client’s hemodynamic status and help determine the severity of the bleeding. This information is essential for guiding further interventions and ensuring the client’s stability.

Choice D rationale

Completing a head-to-toe assessment is important, but it is not the first priority. The initial focus should be on assessing the client’s vital signs to determine their hemodynamic status. A comprehensive assessment can be performed once the client’s immediate condition is stabilized.

A. Flank pain with radiation to the groin, accompanied by hematuria. B. Respiratory distress, chest pain, and use of accessory muscles. C. Crackles, peripheral edema, and weight gain. D. Confusion, decreasing level of consciousness, and aphasia.

Correct Answer is C

Explanation

Choice A rationale

Flank pain with radiation to the groin and hematuria are more indicative of kidney issues, not heart failure.

Choice B rationale

Respiratory distress, chest pain, and use of accessory muscles can indicate respiratory issues but are not specific to heart failure.

Choice C rationale

Crackles, peripheral edema, and weight gain are classic signs of heart failure. These symptoms indicate fluid overload and poor cardiac function.

Choice D rationale

Confusion, decreasing level of consciousness, and aphasia are neurological symptoms and not specific to heart failure.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client arrived via ambulance to the emergency department with a chief complaint of gastrointestinal bleeding for 2 hours. What will the triage nurse do first?

Correct Answer is C

Explanation

When considering the risk for heart failure, what would the nurse monitor the client diagnosed with infective endocarditis for on an ongoing basis?

Correct Answer is C

Explanation

A nurse is assessing a client who is in skeletal traction. The nurse should correct which of the following findings?

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