Your 95-year-old client's vital signs are as follows: oral T 98.6 F: P (radial) 84 with irregularity: R 18. normal depth, & regular: BP (left arm, sitting) 140/86. Which nursing assessment(s) would be done to obtain more data at this time?
Positional BP readings
Carotid pulse and temperature
Full respiratory system assessment
Apical pulse for one minute
The Correct Answer is D
A. Positional BP readings. While orthostatic blood pressure readings can assess for postural hypotension, there is no indication in the current vitals that the client is experiencing symptoms such as dizziness or syncope.
B. Carotid pulse and temperature. The client’s temperature is already documented as normal, and the carotid pulse is not needed when an irregular radial pulse has been noted. The apical pulse is the preferred method to assess for irregularities.
C. Full respiratory system assessment. The respiratory rate is within the normal range, with regular rhythm and normal depth, so a full respiratory assessment is not the immediate priority.
D. Apical pulse for one minute. An irregular radial pulse suggests the possibility of an arrhythmia. The apical pulse provides a more accurate assessment of heart rhythm and rate, ensuring a complete evaluation of the irregularity.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Carotid. The carotid arteries supply blood to the brain, and compressing both simultaneously can reduce cerebral blood flow, potentially causing dizziness, syncope, or loss of consciousness. Therefore, carotid pulses should be assessed one at a time.
B. Radial. The radial pulse can be safely assessed bilaterally at the same time since it does not affect central circulation or brain perfusion.
C. Brachial. The brachial pulse can also be assessed bilaterally without risk, as it does not impact blood flow to critical organs like the brain.
D. Femoral. The femoral pulse can be checked simultaneously on both sides to assess circulation and perfusion, especially in cases of suspected arterial insufficiency.
Correct Answer is B
Explanation
A. Perception. Perception occurs when the brain processes and interprets the pain signal, which happens after the stimulus has been converted and transmitted.
B. Transduction. Transduction is the process where a painful stimulus, such as touching a hot stove, causes cellular damage, leading to the release of chemical mediators that convert the stimulus into a pain impulse.
C. Modulation. Modulation involves the body's response to pain, including the release of endorphins to inhibit pain signals and reduce pain sensation.
D. Transmission. Transmission refers to the movement of the pain impulse from the site of injury to the spinal cord and brain, occurring after transduction has taken place.
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