A nurse is assessing the radial pulse of a patient. The nurse would describe the pulse as brisk and would document this finding as a +2. What is the nurse's documentation describing?

Pulse rhythm

Pulse deficit

C. Pulse amplitude

Pulse arrhythmia

Answer and Explanation

The Correct Answer is C

The correct answer is choice C, Pulse amplitude. Pulse amplitude is a measure of the strength of the pulse and is rated on a 0-4 scale, with 0 indicating no pulse and 4 indicating a bounding pulse. A brisk pulse with a +2 rating suggests a normal pulse strength that is easily felt and is not weak or bounding. Pulse rhythm describes the regularity or irregularity of the pulse beats and is not related to pulse strength. Pulse deficit refers to the difference between the apical and radial pulse rates and is determined by auscultating the apical pulse while simultaneously palpating the radial pulse. Pulse arrhythmia refers to an irregular pulse rhythm.

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Correct Answer is C

Explanation

The correct answer is choice C. The nurse should maintain HIPAA compliance by not sharing any patient information with a non-designated person, even if they identify as a family friend. The nurse should inform the visitor that they cannot share any patient information and suggest that they talk to the patient's family directly if they wish to offer assistance. It is important to protect patient privacy and confidentiality and to only share information with authorized individuals who have a legitimate need to know.

A. Assess pulses, capillary refill, strength, edema, skin, and compare with the other extremity. B. Rebound tenderness in both the arms and legs, skin turgor, and moisture. C. Assess the measurements in centimeters of each extremity, pulses, and varicosities. D. Assess pulses, strength, range of motion, percussion, odor, and edema.

Correct Answer is A

Explanation

The correct answer is choice A. When conducting a physical assessment of the extremities, the most appropriate assessment would be to assess pulses, capillary refill, strength, edema, skin, and compare with the other extremity. This comprehensive assessment can help to identify potential issues with circulation, strength, and skin integrity, and can also provide a baseline for ongoing assessments. Rebound tenderness in both the arms and legs, skin turgor, and moisture (choice B) are not typically assessed during a physical assessment of the extremities. Assessing the measurements in centimeters of each extremity, pulses, and varicosities (choice C) may be appropriate in certain situations, but it is not a comprehensive assessment of the extremities. Assessing pulses, strength, range of motion, percussion, odor, and edema (choice D) is also not a comprehensive assessment of the extremities and may not provide a complete picture of the client's condition. Therefore, the most appropriate assessment when conducting a physical assessment of the extremities is to assess pulses, capillary refill, strength, edema, skin, and compare with the other extremity.

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A nurse is assessing the radial pulse of a patient. The nurse would describe the pulse as brisk and would document this finding as a +2. What is the nurse's documentation describing?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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