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Question 8Type: MCSAThe nurse notes that a patient with Raynaud's disease is more anxious than usual and states, "I don't understand why my hands keep turning colors. It seems to happen when I get upset." What is the nurse’s most appropriate action?1. Discuss how stress can cause the vasospasms in Raynaud's disease and develop a plan to manage stress.2. Discuss using hot water to warm up the patient’s hands and keep them warm.3. Discuss how Raynaud's can impact the patient’s health.4. Implement a no-visitor policy to keep the patient calmer.Correct Answer: Rationale 1: Stress is related to Raynaud's symptoms, and the patient should be taught how to manage stress.Rationale 2: Patients with Raynaud’s may also experience paresthesia of the affected parts, so use of hot water could be dangerous. Using warm water and avoiding exposure to cold are safer.Rationale 3: The patient is likely aware of the effects of Raynaud’s on health. Education time would be better spent on prevention or management.Rationale 4: There is no indication that a no-visitor policy will keep the patient calmer or that it is a good idea.1Global Rationale: Cognitive Level: AnalyzingClient Need: Physiological IntegrityClient Need Sub: Physiological AdaptationNursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 35-3
Question 9Type: MCSAThe nurse is providing preoperative instructions to a patient scheduled for endovascular repair to reduce peripheral vascular disease. The patient asks where the incision will be located. How should the nurse reply?1Global Rationale: Cognitive Level: ApplyingClient Need: Physiological IntegrityClient Need Sub: Physiological AdaptationNursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 35-4