A patient with peripheral arterial disease (PAD) is sitting in a chair and has cool feet that are reddish-purple in color. What action should the nurse take?
Notify the physician.
Evaluate the distal pulses.
Have the patient lie in bed with a pillow under the knees.
Cover the patient with a blanket.
The Correct Answer is B
Choice A reason: Notifying the physician is important, but it is not the immediate action to take. The nurse should first assess the patient's condition before contacting the physician.
Choice B reason: Evaluating the distal pulses is the correct action because it provides information on the blood flow to the extremities, which is crucial for patients with PAD.
Choice C reason: Having the patient lie in bed with a pillow under the knees is not recommended for PAD patients as it can decrease blood flow to the lower extremities.
Choice D reason: Covering the patient with a blanket may provide comfort, but it does not address the underlying issue of impaired blood flow in PAD.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: While relaxation techniques are beneficial, providing structure is often the first step in helping clients with OCD manage their symptoms, as it can reduce anxiety and prevent time for obsessions and compulsions to occur.
Choice B reason: A structured schedule can help the client focus on tasks and activities, reducing the time available for obsessive thoughts and compulsive behaviors.
Choice C reason: Identifying expectations is important, but it should come after establishing a structured routine that can support the client's participation in care.
Choice D reason: Discussing alternative coping strategies is a part of treatment, but initially providing a structured schedule can offer immediate relief and a sense of control for the client.
Correct Answer is A
Explanation
Choice A reason: Catatonia is characterized by symptoms such as extreme muscle rigidity, repetitive speech, and resistance to movement, which align with Lisa's presentation. It is often associated with other mental health conditions but can also be a standalone diagnosis.
Choice B reason: Disorganized schizophrenia is marked by disorganized thinking and behavior, inappropriate emotional responses, and erratic actions. While Lisa's symptoms could suggest a psychotic disorder, they do not specifically indicate disorganized schizophrenia.
Choice C reason: Schizotypal disorder involves eccentric behavior, odd beliefs, and difficulty forming close relationships. Lisa's symptoms do not align with the core characteristics of schizotypal disorder.
Choice D reason: Brief psychotic disorder is a short-term condition that includes delusions, hallucinations, and disorganized speech. Lisa's symptoms could be part of a brief psychotic episode, but the specific mention of muscle rigidity and resistance to movement is more indicative of catatonia.
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