A nurse is caring for a client who has Raynaud's disease. Which of the following actions should the nurse take?

Provide information about stress management.

Administer epinephrine for acute episodes.

Maintain a cool temperature in the client's room.

Give a glucocorticoid steroid twice per day.

Answer and Explanation

The Correct Answer is A

Rationale:

A. Provide information about stress management.: Stress is a major trigger for vasospastic episodes in Raynaud’s disease because it increases sympathetic nervous system activity, causing further arterial constriction. Stress-reduction techniques such as deep breathing, biofeedback, or relaxation exercises helps reduce the frequency and severity of attacks.

B. Administer epinephrine for acute episodes.: Epinephrine causes vasoconstriction, which would worsen Raynaud’s symptoms by further reducing blood flow to the extremities. During an acute episode, warming the affected areas and avoiding additional vasoconstrictors is essential. Epinephrine is not indicated as a treatment and can intensify ischemic discomfort

C. Maintain a cool temperature in the client's room.: Cold temperatures are one of the most common triggers for vasospasm in Raynaud’s disease. A cool environment increase the likelihood of an episode by promoting peripheral vasoconstriction. The nurse should provide a warm environment and encourage protective clothing to maintain circulation.

D. Give a glucocorticoid steroid twice per day.: Steroids are not a standard treatment for Raynaud’s because the condition is related to vasospasm rather than inflammatory processes. Routine steroid use would expose the client to unnecessary adverse effects without addressing the underlying problem. Management strategies focus instead on warmth, lifestyle modification, and vasodilator medications when needed.

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Correct Answer is C

Explanation

Rationale:

A. Fidelity: Fidelity refers to being faithful to commitments and maintaining trust in professional relationships. While important in nursing, it does not specifically relate to equitable distribution of community resources.

B. Autonomy: Autonomy emphasizes respecting an individual’s right to make informed decisions about their own care. Planning a program to ensure equal access addresses fairness, not individual decision-making.

C. Justice: Justice involves fairness in the distribution of resources, benefits, and risks. By ensuring prenatal resources are equally available to all community members, the nurse is practicing the ethical principle of justice and promoting equity in healthcare access.

D. Nonmaleficence: Nonmaleficence focuses on preventing harm to clients. While relevant to all nursing practice, it is not the primary principle guiding equitable allocation of prenatal resources in the community.

A. Stair carpeting is attached with carpet tacks. B. Nonessential items are stored in drawers. C. Magazines are stacked neatly on the stairs. D. End tables are secured to the wall.

Correct Answer is A

Explanation

Rationale:

A. Stair carpeting is attached with carpet tacks: Loose or improperly secured carpeting on stairs creates a significant tripping hazard, especially for clients with mobility limitations such as a hip fracture. Carpet tacks can cause the edges of the carpet to lift, increasing the risk of falls and further injury.

B. Nonessential items are stored in drawers: Storing nonessential items in drawers does not create an immediate fall risk or safety hazard. Keeping items organized in drawers can actually reduce clutter in walking areas, making the environment safer.

C. Magazines are stacked neatly on the stairs: Even neatly stacked magazines on stairs are a potential tripping hazard. However, the option specifies “neatly stacked,” which implies some order, though ideally items should not be on stairs at all. Carpet tacks pose a more immediate and hidden danger than visible items.

D. End tables are secured to the wall: Securing furniture prevents tipping and provides stability, which enhances safety for clients with mobility limitations. This measure decreases the risk of falls and does not pose a hazard.

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A nurse is caring for a client who has Raynaud's disease. Which of the following actions should the nurse take?

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