A nurse is performing a focused assessment for a client who has a dysrhythmia. Which of the following findings indicates ineffective cardiac contractions?

Carotid bruit

Heart murmur

Pulse deficit

Bounding radial pulse

Answer and Explanation

The Correct Answer is C

A. Carotid bruit – A carotid bruit is a vascular sound heard over the carotid artery due to narrowing (stenosis), not an indication of ineffective cardiac contractions.

B. Heart murmur – A heart murmur is caused by abnormal blood flow through heart valves and does not directly indicate ineffective cardiac contractions.

C. Pulse deficit – A pulse deficit occurs when there is a difference between apical and radial pulse rates, indicating ineffective cardiac contractions and poor cardiac output.

D. Bounding radial pulse – A bounding pulse suggests excessive cardiac output or fluid overload, not ineffective contractions.

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

Explanation

A. Observations about family relationships: Personal relationship details are not required unless relevant to care.

B. Response to pain medication: Pain management effectiveness is crucial for continuity of care.

C. Review of ongoing discharge plan: The receiving unit should be aware of discharge plans to provide appropriate care.

D. Recent physical changes: Any changes in condition must be reported for safe care continuation.

E. Comprehensive demographic information: Basic demographic details are in the medical record and do not need to be included in a verbal report.

A. Orange slices B. Ground hamburger C. Cooked green beans D. Canned peaches

Correct Answer is A

Explanation

A. Orange slices: Orange slices should be avoided because they contain a fibrous membrane that can be difficult to chew and swallow, posing a choking risk. Additionally, the acidic nature of oranges may cause irritation in some clients.

B. Ground hamburger: Appropriate for a mechanical soft diet because it is easy to chew and swallow.

C. Cooked green beans: Softened through cooking, making them easy to chew.

D. Canned peaches: Soft and easy to chew, making them suitable for this diet.

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A nurse is performing a focused assessment for a client who has a dysrhythmia. Which of the following findings indicates ineffective cardiac contractions?

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A nurse is performing a focused assessment for a client who has a dysrhythmia. Which of the following findings indicates ineffective cardiac contractions?