A nurse is assessing a client's circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time?

Femoral

Popliteal

Brachial

Carotid

Answer and Explanation

The Correct Answer is D

Assessing the carotid pulse simultaneously on both sides of the neck can potentially lead to excessive pressure on the carotid arteries, which supply blood to the brain. This pressure can compromise blood flow to the brain and result in adverse effects, such as decreased blood supply and oxygenation to the brain tissues.

In clinical practice, it is generally recommended to assess the carotid pulse unilaterally, meaning one side at a time, to ensure adequate blood flow to the brain is maintained during the assessment. This allows for a proper evaluation of the pulse without interfering with the circulatory system.

The other choice are incorrect:

Femoral: Assessing the femoral pulse bilaterally at the same time is generally considered safe. The femoral artery is located in the groin area and provides blood supply to the lower

extremities. Bilateral assessment allows for comparison of pulses and evaluation of circulation in both legs.

Popliteal: The popliteal pulse is located behind the knee. Similar to the femoral pulse, assessing the popliteal pulse bilaterally at the same time is typically safe. It allows for comparison between both legs and evaluation of lower limb circulation.

Brachial: The brachial pulse is located in the upper arm and is commonly used for blood pressure measurement in clinical settings. Assessing the brachial pulse bilaterally at the same time is generally considered safe and is routinely done during blood pressure assessment.

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Correct Answer is ["A","B","E"]

Explanation

The nurse should include the following components when performing a mental status examination (MSE) on a client with a new diagnosis of dementia:

● Grooming: Assessing the client's grooming and personal hygiene can provide insights into their ability to care for themselves and maintain basic activities of daily living.

● Long-term memory: Evaluating the client's long-term memory can help identify any deficits or impairments in their ability to recall past events, experiences, or personal information. This is particularly relevant in dementia, as it often affects memory function.

● Support systems: Assessing the client's support systems, such as family members, friends, or caregivers, is essential in understanding the resources available to the client and the level of assistance they may require in managing their dementia. However, this does not occur within the mental status exam.

● Affect: Evaluating the client's affect refers to observing their emotional expression and responsiveness during the assessment. In dementia, changes in affect can occur, such as a flat affect or inappropriate emotional responses.

The component that should not be included in the MSE for a client with dementia is:

● Presence of pain: While pain assessment is an important aspect of caring for individuals with various health conditions, including dementia, it is not a specific component of the mental status examination. Pain assessment is typically addressed separately and should be conducted when necessary or based on the client's specific complaints or indications of pain.

A. Personal needs B. Communication skills C. Admitting diagnosis D. Perception of the problem

Correct Answer is D

Explanation

The purpose of asking the client to describe their problems during the assessment is to obtain information about their perception of the problem. By asking the client to describe their problems

in their own words, the nurse gains insight into how the client perceives and understands their current situation. This information helps the nurse to understand the client's subjective experience, their concerns, and their specific needs related to the problem. It allows for a more accurate assessment of the client's situation and helps in developing an individualized plan of care tailored to their unique needs.

● Personal needs: While understanding a client’s personal needs is important in providing care, it is not the primary purpose of this specific question. The nurse may ask other questions to gather information about the client’s personal needs.

● Communication skills: Assessing a client’s communication skills may be important in some cases, but it is not the primary purpose of this specific question. The nurse may use other methods to assess the client’s communication skills.

● Admitting diagnosis: The admitting diagnosis is typically determined by a physician and is based on medical tests and examinations. While the nurse may gather information that can contribute to determining the admitting diagnosis, it is not the primary purpose of this specific question.

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A nurse is assessing a client's circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a mental status examination (MSE) on a client who has a new diagnosis of dementia. Which of the following components should the nurse include? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

During the assessment, the nurse asks the client to describe the client's problems. The purpose of this question is to obtain information about what?

Correct Answer is D

Explanation

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