A patient comes in for a physical examination and complains that she was "freezing to death" while waiting for her examination. The nurse notes that her skin is pale and cool, and attributes this finding to:
peripheral vasoconstriction
peripheral vasodilation
venous pooling
decreased arterial perfusion
The Correct Answer is A
A. Peripheral vasoconstriction:
In response to cold, the body constricts peripheral vessels to preserve core temperature, leading to pale, cool skin.
B. Peripheral vasodilation:
Causes warm, flushed skin, not pale and cool.
C. Venous pooling:
Would lead to reddish-blue discoloration and possibly swelling-not pallor and coolness.
D. Decreased arterial perfusion:
Could cause pale and cool skin chronically, but in this case, it's an acute environmental response, not pathological.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "How do other people treat you?":
Not focused on the patient’s safety or suicidal ideation-may divert from the urgent concern.
B. "People often feel hopeless, but the feeling resolves within a few weeks":
Minimizes the patient’s distress and offers false reassurance.
C. "Do you own any lethal weapon?":
Important later in risk assessment, but first establish if the patient has suicidal thoughts.
D. "Are you feeling so hopeless that you feel like hurting yourself now?":
Direct, therapeutic, and necessary. It assesses current suicide risk in a nonjudgmental and supportive way.
Correct Answer is D
Explanation
A. Performs the examination from the left side of the bed:
The standard is to approach from the right side of the bed for consistency in technique.
B. Follows the same examination sequence, regardless of the patient's age or condition:
The sequence may need to be adjusted depending on patient needs (e.g., very ill or pediatric clients).
C. Examines tender or painful areas first to help relieve the patient's anxiety:
Painful areas should be examined last to avoid unnecessary discomfort or guarding.
D. Organizes the assessment to ensure that the patient does not change positions too often:
Promotes comfort and efficiency during the exam.
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