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 A

Explanation

Choice A rationale

Checking the circulation of the affected extremity is crucial because the greatest risk to the client is neuromuscular injury resulting from compartment syndrome. Compartment syndrome is a serious condition that occurs when there’s increased pressure within the muscles, leading to decreased blood flow, which can cause muscle and nerve damage. Early detection and intervention are essential to prevent permanent damage.

Choice B rationale

Administering additional pain medication might provide temporary relief, but it does not address the underlying issue of potential compartment syndrome. Pain unrelieved by medication is a key indicator of this condition, and addressing circulation is the priority.

Choice C rationale

Repositioning the affected extremity might help with comfort, but it does not address the potential for compartment syndrome. The primary concern is ensuring adequate blood flow to prevent tissue damage.

Choice D rationale

Documenting the findings is important for medical records, but it does not address the immediate risk of compartment syndrome. Immediate action to check circulation is necessary to prevent serious complications.

A. Fat neck veins. B. Hypotension. C. Poor skin turgor. D. Bradycardia. E. Pale yellow urine.

Correct Answer is ["B","C"]

Explanation

Choice A rationale

Fat neck veins are not a typical finding in a client with frequent vomiting and diarrhea. Dehydration, which is common in such cases, usually leads to flat neck veins due to reduced intravascular volume.

Choice B rationale

Hypotension is a common finding in clients with frequent vomiting and diarrhea due to fluid loss and dehydration. The loss of fluids leads to a decrease in blood volume, resulting in low blood pressure.

Choice C rationale

Poor skin turgor is a classic sign of dehydration, which is expected in clients with frequent vomiting and diarrhea. Dehydration causes the skin to lose its elasticity, leading to poor skin turgor.

Choice D rationale

Bradycardia is not typically associated with dehydration. In fact, dehydration often leads to tachycardia (increased heart rate) as the body tries to compensate for the reduced blood volume.

Choice E rationale

Pale yellow urine is not a typical finding in dehydration. Dehydration usually leads to concentrated urine, which is darker in color. Pale yellow urine indicates adequate hydration.

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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 nurse is caring for a client who has a full arm cast and reports a pain level of 8 on a scale of 0 to 10, which is unrelieved by pain medication. Which of the following actions should the nurse plan to take first?

Correct Answer is A

Explanation

A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply)

Correct Answer is ["B","C"]

Explanation

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?

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