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

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

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.

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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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

Rationale for Correct Choices:

Serotonin syndrome: The client presents with restlessness, fever, abdominal pain, and disorientation all classic signs of serotonin syndrome. These symptoms developed after a recent dose increase of a serotonergic medication, indicating a likely adverse drug reaction.
Adverse effects of paroxetine: Paroxetine, an SSRI, can cause serotonin syndrome, especially when recently increased or combined with other serotonergic agents. The timing of the dose escalation aligns with the emergence of the client’s acute symptoms.

Rationale for Incorrect Choices:

Psychosis: While disorientation is present, there is no evidence of hallucinations, delusions, or loss of reality testing, which are essential features of psychosis.
Mania: The client does not show signs of elevated mood, grandiosity, pressured speech, or risky behavior, which are typical of mania.
Anxiety: Although anxiety is part of the client’s history, the sudden onset of fever and autonomic instability points more clearly to a toxic reaction rather than worsening anxiety.
Fluoxetine discontinuation: Fluoxetine has a long half-life, and discontinuation typically causes delayed withdrawal symptoms like dizziness or mood swings not the acute systemic symptoms noted here.

A. Select a vein on the back of the hand. B. Clean the site using vigorous friction. C. Use a 22-gauge catheter for insertion. D. Apply a tourniquet firmly above the insertion site.

Correct Answer is C

Explanation

Rationale:

A. Select a vein on the back of the hand: Veins on the dorsum of the hand are often more fragile and prone to infiltration or rupture in older adults. Using a more proximal site, such as the forearm, is generally safer and more stable for IV therapy.

B. Clean the site using vigorous friction: Older adults often have thinner, more delicate skin that can tear easily. While proper antiseptic technique is important, vigorous friction can cause skin trauma and should be avoided during site preparation.

C. Use a 22-gauge catheter for insertion: A 22-gauge catheter is appropriate for older adults because it minimizes vein trauma while still allowing for adequate flow rates. This size is effective for most fluids and medications while reducing the risk of vessel damage.

D. Apply a tourniquet firmly above the insertion site: Applying a tourniquet too tightly can injure fragile veins or cause them to collapse. In older adults, using minimal pressure or alternative vein-dilation methods like warm compresses is often safer.

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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?

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