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.

Answer and Explanation

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.

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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.

A. Obtain the patient's vital signs. B. Give the patient the prescribed as-needed lorazepam. C. Instruct the patient to sit and breathe deeply. D. Instruct the patient in an imagery exercise.

Correct Answer is A

Explanation

Choice A reason: The first step should always be to assess the patient's physical state to rule out any immediate life-threatening conditions before proceeding with psychiatric interventions.

Choice B reason: Administering medication may be necessary, but it should not precede an assessment of the patient's vital signs.

Choice C reason: While instructing the patient to sit and breathe deeply can help alleviate symptoms of anxiety, it is not the first action to take before assessing the patient's vital signs.

Choice D reason: Imagery exercises can be helpful for managing anxiety, but they are not the priority before ensuring the patient's physiological stability.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Lisa is a 22-year-old woman who experiences episodes of extreme muscle rigidity. She sometimes repeats a word or phrase over and over. Attempts to move her are met with increased muscle resistance. What is she exhibiting?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

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