A nurse is preparing to assess a client for pulse deficit. Which of the following actions should the nurse plan to take?
After inflation, deflate a blood pressure cuff on the client's arm while palpating their brachial pulse.
Compare the client's carotid pulse while resting to their carotid pulse after standing for 1 min.
Measure the client's apical pulse while another nurse measures their radial pulse.
Assess both of the client's radial pulses at the same time and compare the quality of pulsations.
The Correct Answer is C
Rationale:
A. After inflation, deflate a blood pressure cuff on the client's arm while palpating their brachial pulse: This technique assesses blood pressure, not pulse deficit. Pulse deficit requires comparing simultaneous heartbeats at different sites rather than using a cuff for measurement.
B. Compare the client's carotid pulse while resting to their carotid pulse after standing for 1 min: This evaluates orthostatic changes in heart rate, not pulse deficit. Pulse deficit specifically identifies a difference between apical and peripheral pulses during the same cardiac cycle.
C. Measure the client's apical pulse while another nurse measures their radial pulse: A pulse deficit is determined by counting the apical pulse and comparing it to the radial pulse simultaneously. A difference indicates that some heartbeats are not producing a palpable peripheral pulse, which is important in conditions like atrial fibrillation.
D. Assess both of the client's radial pulses at the same time and compare the quality of pulsations: Comparing radial pulses on both sides evaluates for peripheral pulse equality or arterial obstruction, not pulse deficit.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Rationale for Correct Choices
• Reye's syndrome: The toddler presents with acute onset of vomiting, lethargy, and altered mental status following a recent viral illness (influenza A). These are hallmark signs of Reye’s syndrome, a rare but serious condition causing hepatic and cerebral dysfunction in children.
• Aspirin administration: Use of aspirin during viral infections in children is strongly associated with the development of Reye’s syndrome. The guardians reported alternating aspirin with acetaminophen, directly increasing the toddler’s risk for this potentially life-threatening condition.
Rationale for Incorrect Choices
• Gastroenteritis: Gastroenteritis typically presents with diarrhea, abdominal cramping, and vomiting. While vomiting is present, the toddler also demonstrates lethargy and neurologic changes, which are not characteristic of routine gastroenteritis.
• Bronchitis: Bronchitis usually causes productive cough, wheezing, or respiratory distress. This toddler has a non-productive cough and clear lung sounds, making bronchitis an unlikely explanation for the current acute neurological and systemic symptoms.
• Oseltamivir administration: Oseltamivir is an antiviral used to treat influenza and is not associated with the development of Reye’s syndrome. The toddler’s severe symptoms are unrelated to this medication.
• Acetaminophen administration: Acetaminophen is generally safe in children at recommended doses. While it can cause liver toxicity in overdose, the scenario indicates appropriate use, making it an unlikely contributor to the toddler’s presentation.
Correct Answer is C
Explanation
A. A single light fixture along the sidewalk may not provide adequate lighting, increasing the risk of falls, and does not reflect proper home safety.
B. A small area rug at the front door can create a tripping hazard, indicating a need for improved safety measures.
C. Changing the batteries in the smoke alarms annually demonstrates that the client is maintaining functional smoke detectors, which is a key aspect of home safety. Regular maintenance of smoke alarms helps prevent fire-related injuries.
D. While a water heater set at 54° C (129.2° F) can prevent scalding, current safety recommendations suggest a slightly lower setting (around 49° C / 120° F) to maximize safety, so this is not the best indicator of proper understanding.
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