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A nurse is preparing to assess a client for pulse deficit. Which of the following actions should the nurse plan to take?

A.

Measure the client's apical pulse while another nurse measures their radial pulse.

B.

After inflation, deflate a blood pressure cuff on the client's arm while palpating their brachial pulse.

C.

Compare the client's carotid pulse while resting to their carotid pulse after standing for 1 min.

D.

Assess both of the client's radial pulses at the same time and compare the quality of pulsations.

Answer and Explanation

The Correct Answer is A

Rationale:

A. Measure the client's apical pulse while another nurse measures their radial pulse: Assessing for a pulse deficit involves comparing the apical and radial pulses simultaneously. A difference between the two indicates that not all heartbeats are reaching peripheral circulation, often seen in arrhythmias like atrial fibrillation.

B. After inflation, deflate a blood pressure cuff on the client's arm while palpating their brachial pulse: This method is used for measuring blood pressure, not for identifying pulse deficits. It does not provide information on the difference between central and peripheral pulse rates.

C. Compare the client's carotid pulse while resting to their carotid pulse after standing for 1 min: This assesses for orthostatic changes, not pulse deficit. Pulse deficit requires comparison of apical and radial pulses, not positional changes in carotid pulse strength or rate.

D. Assess both of the client's radial pulses at the same time and compare the quality of pulsations: Comparing bilateral radial pulses helps detect differences in circulation or vessel obstruction but does not assess for a pulse deficit, which specifically involves apical-radial pulse comparison.


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Related Questions

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B,C"},"C":{"answers":"A,B"},"D":{"answers":"A,B,C"}}

Explanation

Rationale:

  • Sensation: Tingling indicates possible nerve irritation or mild neurovascular compromise. This is often seen in fractures when swelling or bone displacement compresses nerves near the injury site, especially in long bones like the radius.
  • Ecchymosis: Bruising results from soft tissue bleeding and is common in all three conditions due to trauma to blood vessels. Ligament tears (sprain), bone injury (fracture), and capsule damage (dislocation) can all lead to ecchymosis.
  • Pain level: Moderate pain, such as a 4/10 rating, is consistent with both sprains and fractures. Sprains stretch or tear ligaments, while fractures disrupt bone structure. Dislocations usually present with severe, sharp pain that impairs joint movement entirely.
  • Edema: Swelling is a nonspecific but common response to tissue injury. It occurs with ligament strain (sprain), bone disruption (fracture), and joint trauma (dislocation), all of which lead to localized inflammation and fluid accumulation.

Correct Answer is ["B","D","E"]

Explanation

Rationale:

A. A client who moved to an apartment located on higher ground than her previous home: Relocating for safety is a rational coping mechanism and does not, on its own, indicate PTSD. This action reflects adaptation rather than signs of trauma-related distress.

B. A client who has frequent nightmares about the hurricane: Recurrent nightmares related to the traumatic event are a hallmark symptom of PTSD and suggest that the client is experiencing persistent re-experiencing of the trauma.

C. A client who expresses a realization that life will not return to the way it was before the hurricane: This statement reflects acceptance and realistic processing of the event, not necessarily indicative of emotional distress or dysfunction associated with PTSD.

D. A client who describes having persistent feelings of anger about the hurricane: Chronic irritability or anger following trauma is a recognized symptom of PTSD and may indicate the client is struggling with emotional regulation due to unresolved trauma.

E. A client who describes feeling disconnected from those around him following the hurricane: Emotional numbing or detachment from others is a common symptom of PTSD, often associated with difficulty in re-establishing interpersonal connections after trauma.

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