A nurse is reinforcing teaching with a client about how to prevent the onset of manifestations of Raynaud's phenomenon. Which of the following statements should the nurse identify as an indication that the client needs further teaching?
"I will wear gloves when removing food from the freezer."
"I will complete the smoking cessation program I started."
"I will try to anticipate and avoid stressful situations."
"I will keep my house at a cool temperature."
The Correct Answer is D
A. Wearing gloves when removing food from the freezer is appropriate and helps prevent exposure to cold, which can trigger symptoms of Raynaud's phenomenon.
B. Completing a smoking cessation program is beneficial, as smoking can exacerbate symptoms of Raynaud's.
C. Avoiding stressful situations is advisable since stress can trigger vasoconstriction and exacerbate symptoms
.
D. Keeping the house at a cool temperature is not recommended, as cold environments can provoke Raynaud's symptoms; the client should aim to maintain a warm environment to minimize triggers.
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Correct Answer is D
Explanation
A. The nurse should measure the apical pulse for a full minute (not 30 seconds) before administering digoxin. If the pulse is below 60 beats per minute, the medication should be withheld, making this option incomplete.
B. Digoxin should be withheld if the heart rate is below 60/min, not above 100/min. This statement does not reflect proper nursing protocol.
C. Clients taking digoxin should maintain adequate potassium levels, so advising low potassium intake is incorrect. Foods rich in potassium are encouraged.
D. Monitoring for symptoms such as nausea, vomiting, and yellow vision is essential, as these may indicate digoxin toxicity, making this option correct.
Correct Answer is ["B","C"]
Explanation
A. Clients with a basilar skull fracture may experience confusion or memory loss regarding the injury, making them unable to recall how it occurred.
B. Pooling of blood around the eyes, known as "raccoon eyes," is a common sign of a basilar skull fracture.
C. Bruising over the mastoid process (Battle's sign) is another classic sign of a basilar skull fracture, indicating trauma to the base of the skull.
D. Chvostek's sign is associated with hypocalcemia, not basilar skull fractures.