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 C
Explanation
Rationale:
A. "I realize it can be hard to know what to expect at the moment my partner passes away.": This statement shows acknowledgment of the approaching death and emotional preparedness. It reflects acceptance and anticipatory grieving rather than denial.
B. "I have been taking pictures of others who visit with my partner so I can remember these days.": This indicates emotional awareness and an effort to preserve memories, suggesting the partner is coping and processing the impending loss.
C. "I'm shocked everyone has lost hope that my partner will overcome this illness.": This reflects denial, a common early grief reaction where the person struggles to accept the reality of impending death. The partner’s belief that recovery is still possible, despite the terminal prognosis, indicates difficulty facing the truth of the illness.
D. "I have been making arrangements so I can be at my partner's side when they pass away.": This demonstrates planning and emotional acceptance. The partner is preparingwhich reflects adaptive coping rather than denial.
Correct Answer is C
Explanation
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.
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