In assessing the apical heart rate of an adult, in what order should the practical nurse (PN) perform the needed tasks?
Expose the left side of the chest.
Locate the point of maximal impulse.
Position the diaphragm of the stethoscope.
Listen for heart sounds.
The Correct Answer is A,B,C,D
A. Exposing the left side of the chest is the first step to access the area where the apical pulse is assessed. This step ensures that the nurse has clear access to the chest for auscultation.
B. Locating the point of maximal impulse (PMI) is the next step once the chest is exposed. The PMI, typically located at the 5th intercostal space at the midclavicular line, is where the heart’s apex is closest to the chest wall.
C. Positioning the diaphragm of the stethoscope on the PMI is the step where the actual auscultation begins. The diaphragm is used to listen for heart sounds.
D. Listening for heart sounds at the PMI is the final step to assess the apical heart rate. This step completes the assessment by allowing the PN to count the heart rate and evaluate the rhythm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. NSAIDs are not associated with the characteristic features of truncal obesity, moon face, and buffalo hump.
B. Corticosteroids can cause truncal obesity, moon face, and buffalo hump as side effects due to their effects on metabolism and fat distribution.
C. Thyroid replacement hormone is used to treat hypothyroidism and does not cause the symptoms described.
D. Insulin is used to manage diabetes and does not typically cause the features seen in Cushing’s syndrome associated with corticosteroid use.
Correct Answer is ["B","D","F"]
Explanation
A. Avoid discussion of negative situations that may occur in the future.
Not Applicable
Avoiding discussions about potential negative situations is not helpful in addressing caregiver stress. Open and honest conversations about future challenges can prepare caregivers and help them develop coping strategies. Addressing potential issues proactively supports both the caregiver and the care recipient.
B. Involve your mother in the decision-making process.
Applicable
Involving the mother in decision-making helps to validate her feelings and preferences, which can alleviate some of the caregiver’s stress. Shared decision-making respects the mother’s autonomy and can reduce feelings of resentment or frustration from the daughter. This approach fosters a collaborative environment that can ease the caregiver’s burden.
C. Saying "no" to things involving the care of your mother is a selfish action.
Not Applicable
Saying "no" is not a selfish action but a necessary step for maintaining personal well-being. Encouraging caregivers to set boundaries is crucial for managing stress and preventing burnout. Supportive statements should affirm that self-care is essential for effective caregiving.
D. It is okay not to love or like your mother when you are caring for her.
Applicable
Acknowledging that it is okay not to have positive feelings towards the person being cared for can reduce caregiver guilt and stress. Caregivers may experience complex emotions, and recognizing these feelings as normal helps them manage their roles more effectively. This statement supports emotional honesty and resilience in caregiving.
E. Helping your mother should be easier than raising a child.
Not Applicable
Comparing caregiving to raising a child dismisses the unique challenges of elder care and can invalidate the caregiver’s stress. Each caregiving situation is different, and caregivers should be encouraged to recognize and address the specific difficulties they face. Comparisons can be unhelpful and diminish the caregiver’s experiences.
F. Take time for yourself and the other relationships that you care about.
Applicable
Encouraging caregivers to take time for themselves is essential for preventing burnout and maintaining overall well-being. Self-care helps caregivers manage stress and sustain their own health and relationships. This approach supports the caregiver’s needs and acknowledges the importance of balance.
G. You made a promise to your mother that you need to keep.
Not Applicable
Emphasizing promises can increase feelings of guilt or obligation rather than addressing the caregiver’s stress. Caregiver support should focus on practical strategies for managing stress rather than reinforcing burdensome promises. This statement can exacerbate feelings of pressure and strain
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