A client who works as a data entry clerk is concerned as to how a recent diagnosis of Raynaud's syndrome is going to affect the client's job performance. Which instruction should the nurse provide this client?
Obtain a keyboard designed to limit wrist flexion.
Take a multivitamin that contains vitamin D daily.
Keep both hands elevated during work breaks.
Use a space heater to keep the workspace warm.
The Correct Answer is D
A. While obtaining a keyboard designed to limit wrist flexion may be beneficial for ergonomics, it does not specifically address the symptoms or management of Raynaud's syndrome.
B. Taking a multivitamin with vitamin D may not have a direct impact on Raynaud's syndrome and is generally unrelated to the specific concerns of this condition.
C. Keeping hands elevated during breaks does not effectively address the primary concern of temperature regulation that affects Raynaud's syndrome.
D. Using a space heater is a practical measure that can help keep the workspace warm, thereby reducing the likelihood of Raynaud's attacks, which are triggered by cold temperatures and stress.
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Correct Answer is A
Explanation
A. The elevated heart rate and respirations suggest the client may be experiencing hypoxia, especially following a thoracotomy. Administering oxygen will help improve oxygen saturation levels and address potential respiratory distress.
B. While pain management is essential, the immediate concern is ensuring adequate oxygenation.
C. Administering IV fluids may be necessary but is secondary to ensuring the client's oxygenation.
D. Encouraging the client to splint and cough is important for preventing complications but does not address the immediate issue of vital signs indicating possible respiratory compromise.
Correct Answer is C
Explanation
A. A nursing care plan in the medical record before assessing the patient so that the nurse can identify priorities. The nurse should assess the patient first to determine their needs and priorities rather than create a care plan without assessment.
B. At least three times during the shift: at the beginning, in the middle, at the end, and as needed. Regular documentation is good practice, but the initial assessment must be documented at the beginning of the shift to establish a baseline.
C. An initial assessment of the patient and a plan based on the needs of the patient as assessed at the beginning of the shift. Documenting an initial assessment is crucial for identifying immediate needs and planning care, especially after surgery.
D. At the end of the shift so that the nurse can give full attention to the patient's needs during the shift. Waiting until the end of the shift risks missing critical changes and does not provide a clear baseline assessment.