Question

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?

Answer 1

Correct Answers:

Evaluate the distal pulses.

Rationale :

🟤 Peripheral arterial disease (PAD) reduces blood flow to the extremities, and signs like cool, reddish-purple feet indicate poor perfusion or possible dependent rubor, a classic sign of arterial insufficiency.

🟤 The first priority is to assess distal pulses (e.g., dorsalis pedis, posterior tibial) to evaluate the degree of circulation impairment.

🟤 This assessment helps determine if the patient is experiencing critical limb ischemia, which may require urgent intervention.

🟤 If pulses are weak or absent, the nurse should notify the provider promptly for further vascular evaluation or imaging.

🟤 Other actions (e.g., applying warmth or elevating legs with pillows) may worsen arterial flow and are not priority actions before assessment.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Lack of interest
Neglect of personal hygiene

Rationale :

✅ Lack of interest

🟣 Lack of interest, or avolition, is a classic negative symptom of schizophrenia, where the client shows a marked reduction in motivation to initiate and sustain purposeful activities.

🟣 It reflects the loss of normal emotional and behavioral functioning, leading to reduced participation in social, occupational, or recreational activities.

🟣 The individual may appear indifferent, passive, and withdrawn, often needing prompting or encouragement to engage in daily routines.

🟣 This symptom negatively affects functional outcomes, and it often persists even when positive symptoms (like hallucinations) are controlled.

✅ Neglect of personal hygiene

🟣 Poor grooming and hygiene is a hallmark negative symptom reflecting social withdrawal, apathy, and diminished self-care.

🟣 It arises not from willful defiance but from lack of motivation, disorganized thinking, and cognitive deficits, which impair the patient’s ability to carry out basic tasks.

🟣 This neglect can lead to increased health risks, social isolation, and stigma, and often signals functional deterioration.

🟣 Nursing care involves routine prompting, structured schedules, and supportive assistance to improve self-care in these individuals.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

Assist the client to identify triggers to obsessive behaviors.

Rationale :

🧼 In Obsessive-Compulsive Disorder (OCD), compulsive behaviors like repetitive tongue brushing are driven by underlying obsessions or anxiety, and often worsened by certain triggers.

🧼 The priority intervention is to help the client identify what precedes the compulsion, so they can begin to develop awareness and insight—the foundation for treatment and behavioral change.

🧼 Once triggers are identified, the healthcare team can apply exposure and response prevention (ERP) techniques and cognitive-behavioral strategies to interrupt the cycle.

🧼 This approach also helps in preventing physical harm, such as oral ulcerations, by addressing the root cause of the repetitive behavior.

🧼 While other interventions support emotional regulation, identifying behavioral triggers is key to interrupting the OCD loop early and safely.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

Demonstrate nondestructive ways to meet his/her needs.

Rationale :

🟡 A core issue in personality disorders is the use of maladaptive or destructive behaviors (e.g., manipulation, aggression, avoidance) to cope with emotional needs or interpersonal stress.

🟡 The general therapeutic goal is to help the patient develop healthier, more adaptive coping strategies that allow them to meet their needs without harming themselves or others.

🟡 This includes promoting emotional regulation, impulse control, and effective communication, which are often impaired in various types of personality disorders (e.g., borderline, antisocial, narcissistic).

🟡 Building insight into behavior, maintaining boundaries, and managing emotions are all part of achieving nondestructive expression and behavior modification.

🟡 The other options may be long-term aspirations, but learning safe and constructive behavior is foundational and more realistic as a general care goal.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

Seductive

Rationale :

🌺 Clients with histrionic personality disorder exhibit attention-seeking behaviors, often through excessive emotionality and inappropriate sexual or seductive interactions.

🌺 They may use flirtation, charm, or provocative dress to gain attention and approval, especially in social or clinical settings.

🌺 This behavior is usually superficial and dramatic, with rapidly shifting emotions and a strong desire to be the center of attention.

🌺 The nurse should maintain professional boundaries, avoid reinforcing attention-seeking behaviors, and provide clear, calm communication.

🌺 Understanding these traits allows the nurse to provide effective care while preventing manipulation or boundary violations.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

The viscera spilling out of the abdomen

Rationale :

🔴 Evisceration is a surgical emergency where internal organs—most commonly abdominal viscera—protrude through a wound opening, usually after abdominal surgery.

🔴 It typically follows wound dehiscence, which is the partial or complete separation of the surgical incision, but in evisceration, the bowel or other viscera are exposed.

🔴 This condition requires immediate intervention: the nurse should cover the exposed organs with sterile, moist saline dressings, position the patient supine with knees bent, and notify the surgeon immediately.

🔴 Preventing evisceration includes avoiding strain, proper wound support, and close postoperative monitoring, especially in clients with poor healing capacity.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

Reducing anxiety

Rationale :

💉 Opioid analgesics are administered in the postoperative period to provide pain relief, which in turn helps reduce anxiety, restlessness, and stress-related complications.

💉 Pain following thoracic surgery can impair deep breathing and effective coughing, leading to atelectasis or pneumonia. By controlling pain and anxiety, opioids support better respiratory function and recovery.

💉 While opioids may decrease respiratory rate, they do not increase it; therefore, monitoring for respiratory depression is critical.

💉 The goal is to provide comfort, which also improves cooperation with pulmonary hygiene efforts like incentive spirometry or assisted coughing.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Call the surgeon to talk to the patient.

Rationale :

🩺 When a patient expresses fear about not surviving surgery, this may indicate a lack of understanding, unresolved concerns, or a need for more detailed information—issues that fall under the surgeon's responsibility for informed consent.

🩺 The nurse’s role includes recognizing distress and ensuring that the patient’s emotional and informational needs are met by the appropriate provider.

🩺 The surgeon must answer any questions regarding risks, benefits, and outcomes, and help the patient feel sufficiently informed and emotionally prepared for surgery.

🩺 While chaplain services or reassurance may be helpful later, the priority is to address the patient’s specific medical concerns with the right source.

🩺 This action respects both legal and ethical standards in preoperative care.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

The client breathes only when their oxygen levels dip below a certain point.

Rationale :

🫁 In clients with COPD, especially those with chronic CO₂ retention, the normal chemoreceptor response to elevated CO₂ becomes blunted.

🫁 As a result, their respiratory drive becomes primarily dependent on low oxygen levels (hypoxia)—this is known as the hypoxic drive.

🫁 If these clients receive high concentrations of oxygen, their PaO₂ may rise too much, suppressing the hypoxic drive and leading to hypoventilation or respiratory failure.

🫁 For this reason, oxygen is administered conservatively (1–2 L/min via nasal cannula) and with close monitoring of respiratory status and oxygen saturation.

🫁 Understanding this altered drive is critical for safe respiratory management in COPD patients.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

Informed consent.

Rationale :

📃 Informed consent is the legal and ethical process in which the surgeon explains the procedure, including its nature, benefits, risks, and alternatives, and the patient voluntarily agrees to proceed.

📃 Melva's acknowledgment that she understands everything discussed and agrees to the surgery indicates that informed consent has been obtained.

📃 The nurse’s role is to witness the signature, ensure the patient is competent and not under duress, and notify the surgeon if the patient still has questions.

📃 This process ensures patient autonomy and complies with legal standards of care.

📃 It must occur before sedation or anesthesia, and must be properly documented.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

1 :
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?

2 :
A schizophrenic client is being assessed by the nurse. The client is demonstrating negative symptoms. Which symptoms should be considered negative? (select all that apply)

4 :
A general goal for a patient with a Personality Disorder is:

5 :
A nurse is collecting data from a client who has histrionic personality disorder. Which of the following findings should the nurse expect?

6 :
What is evisceration?

7 :
A nurse is caring for a client during the immediate postoperative period following thoracic surgery. When administering an opioid analgesic for pain, the nurse should explain that the medication should have which of the following effects?

8 :
The nurse is assisting in the care of a preoperative patient who states, "I'm really afraid that I won't make it through the surgery." Which action by the nurse is appropriate?

9 :
A client with COPD should receive only 1-2 liters per minute of oxygen, if needed, or they may lose their hypoxic drive. Which of the following statements is correct about hypoxic drive?

10 :
Melva is scheduled for an elective surgery. The surgeon comes to the preoperative area to review the surgical procedure with her. Alternatives are discussed, along with the benefits and risks associated with the surgery. Melva says she understands everything. This is:

QLexNursing

1 : 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?

2 : A schizophrenic client is being assessed by the nurse. The client is demonstrating negative symptoms. Which symptoms should be considered negative? (select all that apply)

4 : A general goal for a patient with a Personality Disorder is:

5 : A nurse is collecting data from a client who has histrionic personality disorder. Which of the following findings should the nurse expect?

6 : What is evisceration?

7 : A nurse is caring for a client during the immediate postoperative period following thoracic surgery. When administering an opioid analgesic for pain, the nurse should explain that the medication should have which of the following effects?

8 : The nurse is assisting in the care of a preoperative patient who states, "I'm really afraid that I won't make it through the surgery." Which action by the nurse is appropriate?

9 : A client with COPD should receive only 1-2 liters per minute of oxygen, if needed, or they may lose their hypoxic drive. Which of the following statements is correct about hypoxic drive?

10 : Melva is scheduled for an elective surgery. The surgeon comes to the preoperative area to review the surgical procedure with her. Alternatives are discussed, along with the benefits and risks associated with the surgery. Melva says she understands everything. This is:

1 :
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?

2 :
A schizophrenic client is being assessed by the nurse. The client is demonstrating negative symptoms. Which symptoms should be considered negative? (select all that apply)

4 :
A general goal for a patient with a Personality Disorder is:

5 :
A nurse is collecting data from a client who has histrionic personality disorder. Which of the following findings should the nurse expect?

6 :
What is evisceration?

7 :
A nurse is caring for a client during the immediate postoperative period following thoracic surgery. When administering an opioid analgesic for pain, the nurse should explain that the medication should have which of the following effects?

8 :
The nurse is assisting in the care of a preoperative patient who states, "I'm really afraid that I won't make it through the surgery." Which action by the nurse is appropriate?

9 :
A client with COPD should receive only 1-2 liters per minute of oxygen, if needed, or they may lose their hypoxic drive. Which of the following statements is correct about hypoxic drive?

10 :
Melva is scheduled for an elective surgery. The surgeon comes to the preoperative area to review the surgical procedure with her. Alternatives are discussed, along with the benefits and risks associated with the surgery. Melva says she understands everything. This is: