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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?

A.

Thready pulse volume

B.

Missing pulse.

C.

Light pressure applied to pulse

D.

Pulse skips beats

Answer and Explanation

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:

  1. 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.
  2. Light pressure applied to pulse is not a documentation of the pulse quality, but a description of the technique used to palpate the pulse.
  3. 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.
 
  MedicosNotes.com: What are the causes of low volume pulse?


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Related Questions

Correct Answer is D

Explanation

The correct answer is Choice D

Choice A: Excruciating pain

  • Rationale: While partial thickness burns can be painful, especially in the first few days, excruciating pain is less likely for a stable patient 3 days post-burn. Pain management is a crucial aspect of burn care, but excruciating pain might indicate deeper burns or complications like infection.

Choice B: Elevated blood pressure

  • Rationale: Elevated blood pressure is not a typical complication of a partial thickness burn. In fact, burn patients are more at risk for hypotension (low blood pressure) due to fluid loss.

Choice C: Compartment syndrome

  • Rationale: Compartment syndrome is a serious complication that typically occurs with deep burns or traumatic injuries. It's caused by increased pressure within a muscle compartment, restricting blood flow and potentially leading to tissue death. While a possibility, it's less likely for a partial thickness burn 3 days after the injury.

Choice D: Curling's Ulcer

  • Rationale: Curling's ulcer is a peptic ulcer (stomach ulcer) that can develop as a complication of major burns. This is because burns trigger a massive inflammatory response, releasing stress hormones that increase stomach acid production, making the stomach lining more susceptible to ulcers. Given the extensive burn area (30% TBSA) and the timeframe (3 days post-burn), Curling's ulcer becomes a significant concern.

Therefore, the correct answer is: Choice D: Curling's Ulcer

Explanation:

  • A 30% TBSA partial thickness burn is a significant injury that triggers a systemic inflammatory response.
  • Three days post-burn falls within the timeframe when Curling's ulcer can develop due to the increased stress hormones and gastric acid production.
  • While pain management and monitoring for compartment syndrome are important, Curling's ulcer poses a more significant threat in this scenario.

Correct Answer is ["A","C","D"]

Explanation

The correct answer is choice A, C, and D. Choice A rationale: Boiled brown rice is a good option for a client with renal disease needing to limit salt intake. It is low in sodium and does not contribute to fluid retention. Choice B rationale: Canned tomato soup is typically high in sodium, which can lead to fluid retention and increased blood pressure, making it an unsuitable choice for someone with renal disease who needs to limit salt intake. Choice C rationale: Fresh orange slices are low in sodium and high in vitamin C. They do not contribute to fluid retention and are suitable for a client with renal disease on a low-salt diet. Choice D rationale: Grilled chicken, especially if not seasoned with salt, is a low-sodium protein source that fits within the dietary restrictions for a client with renal disease. Choice E rationale: Vegetables are generally a good choice, but topping them with cheddar cheese increases the sodium content significantly, making it an inappropriate choice for someone on a low-salt diet, as cheese is often high in sodium.

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