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: Convection involves the movement of air or liquid around the body, which then carries heat away but does not involve phase change like evaporation.
B: Evaporation is the process where liquid (sweat) turns into vapor, removing heat from the surface it evaporates from, which is the primary cooling mechanism in sweating.
C: Conduction involves direct transfer of heat through contact with cooler objects, not relevant to the drying of sweat.
D: Radiation refers to heat transfer through electromagnetic waves and does not require the presence of an intervening medium, unlike the evaporation of sweat.
Correct Answer is D
Explanation
A: The cuff should ideally cover about 80% of the circumference of the upper arm, not just 50%.
B: The cuff should be placed level with the client's heart, specifically aligned with the brachial artery for accurate measurement.
C: Elevating the arm above the level of the heart can lead to an inaccurately low reading.
D: Proper alignment with the brachial artery ensures that the sensor correctly detects the arterial pressure, crucial for accurate readings.
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