An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers. After warming her hands, the fingers turn red and the client reports a burning sensation. What action should the nurse take?

Correct Answer: D

Rationale: In this scenario, the correct action for the nurse to take is to continue to monitor the fingers until the color returns to normal (Option D). This is because the client is exhibiting symptoms of Raynaud phenomenon, a condition characterized by vasospasm of the blood vessels in response to cold or stress. In Raynaud phenomenon, fingers first turn pale due to reduced blood flow, then cyanotic due to lack of oxygen, and finally red with a burning sensation as blood flow returns. Applying a cool compress (Option A) would exacerbate the vasoconstriction and worsen the symptoms. While monitoring oxygen saturation with a pulse oximeter (Option B) is important in some cases, it is not the priority here as the issue is related to vasospasm rather than decreased oxygenation. Reporting the finding to the healthcare provider (Option C) may be necessary eventually, but immediate intervention to address the vasospasm is more crucial in this acute situation. Educationally, this question highlights the importance of understanding the pathophysiology of Raynaud phenomenon and the appropriate nursing interventions. It underscores the need for nurses to recognize and respond to vascular disorders promptly to prevent further complications and provide optimal care for clients with such conditions.

Correct Answer: B

Rationale: The correct answer is B) Practice inhaling through the nose and exhaling slowly through pursed lips. This technique, known as pursed lip breathing, helps to slow down breathing, improve oxygen exchange, and reduce shortness of breath in patients with emphysema. It prevents small airways from collapsing, making breathing more efficient. Option A is incorrect because allowing additional time for physical activities does not directly address dyspnea management in emphysema. It may help reduce oxygen demand but does not teach the client a specific technique to manage dyspnea. Option C is incorrect as using a humidifier may be beneficial for some respiratory conditions, but it is not the most effective strategy for managing dyspnea in emphysema. Emphysema is characterized by air trapping in the lungs, not necessarily related to air humidity. Option D is also incorrect because strengthening abdominal muscles through leg raises does not directly target dyspnea management in emphysema. While overall physical fitness is important, specific breathing techniques like pursed lip breathing are more effective for dyspnea control in emphysema. In an educational context, it's important for nurses to understand and teach evidence-based strategies for managing respiratory conditions like emphysema. Teaching patients effective breathing techniques empowers them to take control of their symptoms and improve their quality of life. Nurses play a crucial role in educating patients on self-management strategies to promote better health outcomes.

Correct Answer: C

Rationale: In this scenario, option C is the most useful information in determining the possible cause of the exacerbation of eczema symptoms. The presence of a new dog can trigger allergic reactions in individuals with eczema due to pet dander and potential allergens present in the dog's fur or saliva. This information is crucial as it points towards a potential trigger for the worsening of symptoms. Option A is incorrect as the presence of a friend with eczema does not directly correlate with the exacerbation of the client's symptoms unless there was direct contact leading to an allergic reaction. Option B is less likely to be the cause as receiving an influenza immunization typically does not exacerbate eczema symptoms unless the client has a specific allergic reaction to the vaccine components. Option D is also less likely to be the cause as corticosteroid cream is a common treatment for eczema and should not worsen symptoms unless the cream itself is expired or contaminated. From an educational perspective, this question highlights the importance of understanding potential triggers for eczema exacerbations, such as exposure to new allergens like pet dander. It emphasizes the need for nurses to conduct thorough assessments and gather relevant information to identify and address the root cause of a client's worsening symptoms effectively.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Pain when swallowing, which warrants immediate intervention by the nurse. The rationale for this choice is that pain when swallowing can indicate potential complications such as esophagitis or opportunistic infections like candidiasis, which are common in individuals with AIDS. These conditions can further compromise the client's respiratory status and lead to serious complications, making it crucial for the nurse to address this symptom promptly to prevent further deterioration in gas exchange. Option A) Elevated temperature is a common sign of infection, which is important to monitor but may not directly impact gas exchange as urgently as pain when swallowing in this context. Option B) Generalized weakness is a non-specific symptom that may be seen in various conditions and does not directly address the immediate respiratory concerns. Option C) Diminished lung sounds could indicate respiratory compromise, but given the client's specific condition of impaired gas exchange from a respiratory infection, the symptom of pain when swallowing takes precedence in terms of urgency for intervention. In an educational context, understanding the priority of symptoms and assessments in clients with complex conditions like AIDS is crucial for nurses caring for these individuals. Recognizing the significance of certain symptoms over others based on their potential impact on the client's health is a key aspect of providing effective and timely nursing care in such cases. By prioritizing interventions based on the client's specific needs and condition, nurses can optimize patient outcomes and ensure high-quality care delivery.

Correct Answer: D

Rationale: The most important finding for the nurse to report to the healthcare provider in this scenario is option D) Jaundiced sclera. Jaundice is a serious sign of liver dysfunction, which could be indicative of a potential infection such as hepatitis, especially considering the recent travel to a tropical climate where infectious diseases may be more prevalent. Liver involvement can lead to serious complications, especially in pediatric patients. Option A) Weakness and fatigue are non-specific symptoms that can be associated with various conditions and may not provide a clear indication of the underlying issue. Option B) Intestinal cramping, while uncomfortable for the client, is a common symptom of diarrhea and may not necessarily point to a more serious condition. Option C) Weight loss, while significant, may be a consequence of the diarrhea and not necessarily the most critical finding requiring immediate attention. In an educational context, understanding the significance of specific symptoms and their implications in pediatric patients is crucial for nurses caring for children with potential health concerns. Recognizing the priority signs and symptoms to report to healthcare providers can lead to timely interventions and improved outcomes for pediatric patients.