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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
An evolving consumer household, also known as a supported or assisted living arrangement, is designed to provide individuals with a greater level of independence and autonomy compared to a traditional group home setting. The emphasis is on empowering clients to develop and enhance their skills and abilities to live more independently.
By transitioning to an evolving consumer household, the ultimate goal is for the client to be able to fulfill their daily responsibilities without constant supervision. This includes activities such as managing their personal care, household tasks, budgeting, meal preparation, and other essential activities of daily living. The aim is to promote self-sufficiency and a sense of personal agency, enabling the client to become more self-reliant and self-directed in their daily life.
While meeting with a therapist on a weekly basis may be a component of the client's overall treatment plan, it is not the primary goal of transitioning to an evolving consumer household. The focus is more on developing independent living skills rather than solely on therapeutic interventions.
Similarly, although emotional support from paid staff may be available in the evolving consumer household, the goal is not to solely rely on increased emotional support but rather to gradually reduce the need for constant support and supervision.
Resolving crises within a shorter time period is an important aspect of care in any setting, but it is not specifically tied to the transition from a group home to an evolving consumer household. Crisis management skills and strategies can be addressed in various settings to ensure the client's well-being and safety.
Correct Answer is C
Explanation
When creating a plan of care for a client experiencing a situational crisis, it is important to set measurable and obtainable goals that can guide the client's progress and provide clear indicators of achievement.
Considering the options provided, the most measurable and obtainable goal for the client experiencing a situational crisis would be:
The client will resume the pre-crisis level of functioning.
This goal is measurable as it involves assessing the client's functioning before the crisis and monitoring their progress in returning to that level. It is also obtainable as it focuses on restoring the client's previous abilities and skills, rather than relying on subjective or introspective factors. By setting specific criteria to determine the pre-crisis level of functioning and regularly evaluating the client's progress, the nurse can measure the client's achievement of this goal and adjust the plan of care accordingly.
The client will resume the pre-crisis level of functioning: Resuming the pre-crisis level of functioning is a measurable and obtainable goal. It involves identifying the client's previous level of functioning and working towards returning to that state. By assessing the client's functional abilities before the crisis and monitoring progress over time, it is possible to measure and track the extent to which they have regained their previous level of functioning.
The client will discover a new sense of self-sufficiency in coping: While this goal is important for the client's long-term growth and development, it is not easily measurable or obtainable in a specific timeframe. "Discovering a new sense of self-sufficiency" is a subjective and introspective process that may require extensive self-reflection and personal growth, making it difficult to measure and set a concrete timeline for achievement.
The client will express anger regarding the crisis event: Expressing anger can be a normal and healthy part of the healing process during a crisis. However, it is not necessarily the most
measurable or obtainable goal. The expression of anger can vary greatly among individuals, and it may not be an appropriate or necessary response for everyone. Additionally, the focus of the plan of care should extend beyond anger expression and encompass a broader range of emotions and coping strategies.
The client will identify possible causes for the crisis: While understanding the possible causes of the crisis can be an important part of the recovery process, it may not be the most measurable or obtainable goal on its own. Identifying the causes of a crisis can involve complex factors that may require professional assessment and a deeper exploration of the client's history and circumstances. It is more appropriate as an ongoing process within therapy rather than a specific goal with a clear endpoint.
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