The nurse finds a client's pulse to be very weak, but palpable. Documentation should note that this pulse is:
hypovolemic.
bradycardic.
deficient.
thready.
The Correct Answer is D
D. A "thready" pulse is weak and difficult to palpate. It feels like a fine thread or string under the fingertips and suggests poor cardiac output or decreased peripheral perfusion. A thready pulse is palpable but weak, indicating inadequate stroke volume with each heartbeat.
A. Hypovolemic refers to a state of decreased blood volume, which can lead to a weak and rapid pulse due to reduced blood flow through the arteries. However, it does not specifically describe the quality of the pulse that is palpable.
B. Bradycardia refers to a slow heart rate, typically below 60 beats per minute in adults. A bradycardic pulse may be slow but can still be strong or weak depending on the underlying cause. It does not specifically describe the quality of a weak but palpable pulse.
C. "Deficient" is not a commonly used term to describe the quality of a pulse. It does not provide specific information about the palpable nature or strength of the pulse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. This problem indicates that the client is not receiving adequate nutrition to meet metabolic needs, which can lead to malnutrition and compromised healing. Addressing imbalanced nutrition is crucial for maintaining health and supporting recovery.
A. This problem refers to disturbances in sexual function or satisfaction. While important to address, it is not typically considered a high priority compared to other physiological or safety-related issues unless it B This problem indicates the potential for the client to experience loneliness or social disconnection, which can impact mental and emotional well-being. While addressing social isolation is important for holistic care, it may not be as urgent as issues related to physical health or safety.
C This problem indicates the inability to endure physical activities or exercise due to insufficient physiological or psychological energy. Activity intolerance can be a significant concern post-operatively or in clients with chronic conditions, as it can affect recovery and overall functional ability.
Correct Answer is ["B","C","E"]
Explanation
B. According to Medicare and The Joint Commission guidelines, the use of patient restraints requires a physician's order. The order should specify the reason for the restraint, the type of restraint, and the duration or conditions for its use.
C. Before using restraints, healthcare providers must exhaust all alternative, less restrictive measures to manage the patient's behavior or condition. This could include environmental modifications, reassurance techniques, or pharmacological interventions.
E. Restraints should be removed or released every 2 hours for reevaluation and to provide opportunities for range of motion exercises, toileting, hydration, and skin care. Restraints should not be used continuously without periodic assessment and reevaluation.
A. Punitive measures are not appropriate or effective in the use of patient restraints. Restraints should only be used for medical reasons to ensure patient safety, not as a form of punishment.
D. Inadequate staffing is not a criterion specified for using patient restraints. Restraints should not be used as a substitute for sufficient staffing levels to monitor and manage patient care.
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