A nurse is caring for a client who has a dysrhythmia. Which of the following techniques is appropriate for the nurse to use to assess for a pulse deficit?

Obtain apical and radial rates simultaneously.

Palpate pulses in the lower extremities.

Check blood pressure in left and right arms.

Compare the pulse strength in upper extremities.

Answer and Explanation

The Correct Answer is A

A. Obtaining apical and radial rates simultaneously allows the nurse to assess for a pulse deficit by comparing the two rates. A pulse deficit is present when the apical rate (heard with a
stethoscope) is greater than the radial rate (palpated at the wrist).

B.   Palpating pulses in the lower extremities is not specific for assessing a pulse deficit and may not accurately reflect the cardiac output.

C.   Checking blood pressure in left and right arms assesses for blood pressure differences but does not specifically address a pulse deficit.
D.   Comparing the pulse strength in the upper extremities does not directly assess for a pulse deficit; simultaneous assessment of apical and radial rates is more appropriate.

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Correct Answer is A

Explanation

A. Surveying the target population is the best approach to identify the specific interests and

health concerns of the older adults, ensuring that the programs are relevant and tailored to their needs.
B. Determining the availability of health care providers is a logistical consideration but may not necessarily address the specific interests or needs of the older adults.
C. Basing the programs on their developmental stage is important, but surveying the population allows for a more comprehensive understanding of their diverse needs and preferences.
D. Reviewing Healthy People 2020 Objectives is a valuable resource, but it may not capture the specific interests or concerns of the local population.

A. "I am trying to understand why this had to happen to me." B. "I dread going to therapy, but I am getting comfortable with my prosthesis." C. "My leg looks a little red, but my doctor says it's healing well." D. "I may be ready to talk about my leg in a week or so."

Correct Answer is B

Explanation

A. Expressing a desire to understand why the amputation happened suggests the client is still grappling with acceptance.
B. Expressing discomfort with therapy but being comfortable with the prosthesis indicates an acknowledgment of the loss and adaptation to the situation.
C. Noting the leg's appearance and healing is an observation but does not necessarily indicate acceptance.
D. Indicating a readiness to talk about the leg in a week or so suggests the client is not currently ready to discuss or fully accept the loss.

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