Which instruction should the nurse provide a client who was recently diagnosed with Raynaud’s disease?

Choice A reason: Obtaining another blood pressure measurement is critical, as lethargy, pallor, and diaphoresis suggest hypotension or shock, despite the earlier 140/90 reading. This guides safe administration of antihypertensives, preventing harm, per cardiovascular assessment and medication safety protocols in nursing practice.

Choice B reason: Determining recent medications is important but secondary to assessing current blood pressure, as symptoms suggest acute instability. Blood pressure confirms hypotension risk before reviewing drugs, ensuring timely intervention, per cardiovascular assessment and patient safety standards in nursing care.

Choice C reason: Administering antihypertensives without reassessing blood pressure is unsafe, as lethargy, pallor, and diaphoresis indicate possible hypotension. Confirming blood pressure prevents exacerbating instability, per medication safety and cardiovascular monitoring protocols in nursing practice for clients with hypertension.

Choice D reason: Consulting the PN about the 0800 condition delays immediate assessment of current symptoms. Blood pressure measurement addresses acute lethargy, pallor, and diaphoresis, guiding intervention. Consultation is secondary, per prioritization and cardiovascular assessment standards in nursing care.

Choice A reason: Using a heating pad is contraindicated in Raynaud’s, as reduced sensation from vasospasm risks burns. Raynaud’s involves cold-triggered arteriolar constriction, reducing blood flow. Heat does not address vasospasm’s pathophysiology and may cause tissue damage, making this instruction inappropriate compared to cold protection strategies.

Choice B reason: Wearing gloves when handling cold items prevents vasospasm in Raynaud’s, where cold triggers arteriolar constriction, causing ischemia and pain. Protecting extremities maintains blood flow, preventing episodes. This directly addresses the disease’s pathophysiological trigger, making it the most effective instruction for managing Raynaud’s symptoms.

Choice C reason: Knee-high support stockings improve venous return, relevant for venous insufficiency, not Raynaud’s arterial vasospasm. Stockings do not prevent cold-induced vasoconstriction, the primary trigger. Gloves for cold exposure directly mitigate vasospastic episodes, making this instruction less effective for Raynaud’s disease management.

Choice D reason: Regular walking improves overall circulation but does not prevent Raynaud’s vasospastic episodes, triggered by cold or stress. While exercise supports vascular health, avoiding cold exposure with gloves is more targeted, directly reducing arteriolar constriction and ischemic symptoms, making walking a secondary recommendation.