The practical nurse (PN) palpates a client's radial pulse and notes that the pulse disappears when light pressure is applied.
How should the PN document this finding?
Thready pulse volume
Missing pulse.
Light pressure applied to pulse
Pulse skips beats
The Correct Answer is A
A thready pulse is a weak and rapid pulse that is easily obliterated by light pressure. It indicates poor blood flow and perfusion, and may be caused by conditions such as shock, dehydration, or hemorrhage.
The other options are not correct because:
- A missing pulse is a pulse that is absent or cannot be detected, even with firm pressure. It indicates a complete blockage of blood flow, and may be caused by conditions such as arterial occlusion, embolism, or trauma.
- Light pressure applied to pulse is not a documentation of the pulse quality, but a description of the technique used to palpate the pulse.
- Pulse skips beats is a documentation of an irregular pulse rhythm, not a pulse volume. It indicates that the heart beats are unevenly spaced, and may be caused by conditions such as arrhythmia, stress, or caffeine intake.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A: Record the findings and report the symptoms to the charge nurse.
Choice A rationale:
The practical nurse (PN) should first record the client's findings, including the progressively decreasing appetite, increased daytime bed hours, and refusal to participate in planned activities. This documentation is essential for accurate communication and continuity of care. After recording the findings, the PN should promptly report the symptoms to the charge nurse. Reporting allows for timely intervention and assessment by the charge nurse or other healthcare providers to address the client's issues effectively.
Choice B rationale:
Asking family members to visit more often is not the best action to take in this situation. While family support is important, the client's symptoms suggest possible underlying health concerns that need professional evaluation and management. Relying solely on increased family visits might delay appropriate healthcare interventions.
Choice C rationale:
Motivating the client by offering their favorite foods as a prize might not be appropriate at this stage. The client's decreased appetite and refusal to participate in activities could be indicators of underlying health issues that need to be addressed first. Moreover, encouraging unhealthy eating habits as a "prize”. could be counterproductive to the client's well-being.
Choice D rationale:
Withholding medications that may cause side effects is not a suitable action without consulting the healthcare provider responsible for the client's care. Abruptly stopping medications could lead to adverse effects or complications, and it is essential to involve the healthcare team in making decisions about medication management.
Correct Answer is D
Explanation
The correct answer is
Choice D rationale:
The practical nurse (PN) should review the client's risk factors for exercise intolerance that impact his quality of life. By doing so, the PN can assess the client's overall health and identify any potential issues that might contribute to his fatigue. This response shows the PN's concern for the client's well-being and is focused on exploring the root cause of his tiredness.
Choice A rationale:
Determining if the client can move to a residential home without lawn maintenance is not appropriate in response to his complaint about feeling tired. This option does not address the underlying issue and assumes the client is unable to care for his own lawn, which may not be the case.
Choice B rationale:
Recommending that the client retires from doing outdoor chores is also not appropriate. It assumes the client's fatigue is solely due to his age and disregards the possibility of other contributing factors that might be addressed.
Choice C rationale:
Advising the client that fatigue is a common characteristic of aging is not a comprehensive response. While fatigue can be related to aging, it is crucial to explore the specific reasons for the client's tiredness before assuming it is solely age-related.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.