A nurse performing an assessment would correctly note that an absent pulse in one or more of the extremities indicates
Decreased plasma volume.
Problems with the heart's electrical conduction system.
Shock.
A blockage of blood flow.
The Correct Answer is D
A. Decreased plasma volume might cause overall weak pulses but would unlikely cause an absent pulse specifically localized in one or more extremities. Decreased plasma volume generally affects circulation systemically, not selectively in certain limbs.
B. Problems with the heart's electrical conduction system primarily affect the rhythm and rate of the heart but do not directly cause absent pulses in extremities. These issues lead to irregular or abnormal heartbeats, not localized absence of pulses.
C. Shock can result in weak or thready pulses due to poor blood flow, but shock alone would not typically cause a pulse to be completely absent in one extremity while present in others. Shock affects the circulatory system as a whole.
D. A blockage of blood flow is the most likely cause of an absent pulse in one or more extremities. This could be due to atherosclerosis, embolism, or thrombosis, which can obstruct blood flow in specific areas, leading to no detectable pulse in those extremities.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A: Sonorous wheezes are low-pitched sounds and do not describe fine rales.
B: Musical or whistling sounds typically describe wheezes which are continuous and not the discontinuous sound of rales.
C: Noisy, snoring sounds are characteristic of rhonchi, not rales.
D: Fine rales are high-pitched, brief, and discontinuous crackling sounds that are often likened to the sound of hair being rubbed between fingers, indicative of fluid in the small airways.
Correct Answer is B
Explanation
A: Hypoglycemia does not directly correlate with a lower heart rate.
B: A heart rate of 56/min may indicate bradycardia, which can lead to symptoms like dizziness due to decreased cardiac output and subsequently reduced cerebral perfusion.
C: A fever would typically increase the heart rate, not decrease it.
D: Cigarette smoking is more commonly associated with an increased heart rate due to stimulants like nicotine.
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