A nurse performing an assessment would correctly note that an absent pulse in one or more of the extremities indicates
Decreased plasma volume.
Problems with the heart's electrical conduction system.
Shock.
A blockage of blood flow.
The Correct Answer is D
A. Decreased plasma volume might cause overall weak pulses but would unlikely cause an absent pulse specifically localized in one or more extremities. Decreased plasma volume generally affects circulation systemically, not selectively in certain limbs.
B. Problems with the heart's electrical conduction system primarily affect the rhythm and rate of the heart but do not directly cause absent pulses in extremities. These issues lead to irregular or abnormal heartbeats, not localized absence of pulses.
C. Shock can result in weak or thready pulses due to poor blood flow, but shock alone would not typically cause a pulse to be completely absent in one extremity while present in others. Shock affects the circulatory system as a whole.
D. A blockage of blood flow is the most likely cause of an absent pulse in one or more extremities. This could be due to atherosclerosis, embolism, or thrombosis, which can obstruct blood flow in specific areas, leading to no detectable pulse in those extremities.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: Tachypnea refers to rapid breathing, typically defined as a respiratory rate exceeding 20 breaths per minute.
B: Bradypnea is characterized by abnormally slow breathing, with a respiratory rate below the normal range.
C: Eupnea describes normal breathing, with a respiratory rate within the typical range for the patient's age and health status.
D: Apnea is the absence of breathing, not merely a decreased rate, and is considered a medical emergency.
Correct Answer is B
Explanation
A: Subjective information refers to what the patient experiences and reports, not what is sensed by the observer.
B: Objective signs are those that can be observed and measured by someone other than the patient, such as visual inspections, palpations, and auditory cues.
C: Reported by the patient would be subjective data, opposite of what is sensed and recorded by healthcare providers.
D: Hidden signs would imply they are not readily observable, which contradicts the use of senses to identify them.
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