A nurse is assessing a client's circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time?
Femoral
Popliteal
Brachial
Carotid
The Correct Answer is D
Assessing the carotid pulse simultaneously on both sides of the neck can potentially lead to excessive pressure on the carotid arteries, which supply blood to the brain. This pressure can compromise blood flow to the brain and result in adverse effects, such as decreased blood supply and oxygenation to the brain tissues.
In clinical practice, it is generally recommended to assess the carotid pulse unilaterally, meaning one side at a time, to ensure adequate blood flow to the brain is maintained during the assessment. This allows for a proper evaluation of the pulse without interfering with the circulatory system.
The other choice are incorrect:
Femoral: Assessing the femoral pulse bilaterally at the same time is generally considered safe. The femoral artery is located in the groin area and provides blood supply to the lower
extremities. Bilateral assessment allows for comparison of pulses and evaluation of circulation in both legs.
Popliteal: The popliteal pulse is located behind the knee. Similar to the femoral pulse, assessing the popliteal pulse bilaterally at the same time is typically safe. It allows for comparison between both legs and evaluation of lower limb circulation.
Brachial: The brachial pulse is located in the upper arm and is commonly used for blood pressure measurement in clinical settings. Assessing the brachial pulse bilaterally at the same time is generally considered safe and is routinely done during blood pressure assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Systematic desensitization is a therapeutic technique used to help individuals gradually overcome their fears or phobias by exposing them to the feared stimulus in a controlled and systematic way. The goal is to reduce anxiety and increase relaxation through a step-by-step process.
The statement "What is the worst that will happen if you confront this fear?" aligns with the principle of systematic desensitization because it encourages the client to explore and challenge their negative beliefs or catastrophic thinking associated with their fear. By questioning the potential negative outcomes, the nurse is helping the client to reevaluate their fear response
and consider more realistic expectations. This process can contribute to the client's ability to confront their fear gradually and reduce anxiety over time.
The other statements are still helpful and supportive, but they do not specifically address the principles of systematic desensitization:
“I can see you are anxious. Let's stop for a minute." acknowledges the client's anxiety but does not actively engage in the technique of systematic desensitization.
"Use the deep breathing techniques we practiced yesterday." focuses on relaxation techniques, which can be helpful in managing anxiety but does not specifically address the principles of systematic desensitization.
“Tell me how you are feeling right now." encourages the client to express their feelings but does not directly engage in the technique of systematic desensitization.
Correct Answer is B
Explanation
When discussing culturally competent care at a nursing staff inservice, the nurse should include information about the importance of focusing on clients’ cultures when providing care. Culture plays a significant role in determining when a client will seek medical care and how they will respond to treatment. Nonverbal communication is important in many cultures and can provide valuable information about a client’s needs and preferences. Nurses should strive to provide care that is respectful of and responsive to clients’ cultural beliefs and practices, rather than expecting clients to adapt to the care provided.
● “Culture plays no role in determining when a client will seek medical care.” This statement is incorrect because culture can play a significant role in determining when and how a client seeks medical care. Cultural beliefs and practices can influence a client’s understanding of health and illness, their attitudes towards healthcare providers, and their willingness to seek and adhere to treatment.
● “Nonverbal communication is important in few cultures.” This statement is incorrect because nonverbal communication is important in many cultures. Nonverbal cues such as body language, facial expressions, and gestures can convey important information about a client’s emotions, needs, and preferences. Understanding and responding to nonverbal communication can help nurses provide culturally competent care.
● “Nurses should expect clients to adapt to the care provided regardless of culture.” This statement is incorrect because it is not culturally competent to expect clients to adapt to the care provided without considering their cultural beliefs and practices. Nurses should strive to provide care that is respectful of and responsive to clients’ cultural beliefs and practices. This may involve adapting the care provided to meet the unique needs of each client.
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