During a physical assessment, the nurse should implement which actions initially when determining if a client's radial pulse is irregular? (Select all that apply.)

Wait until the end of the physical assessment to reassess the radial pulse.

Reassess the client's pedal pulse on the other foot.

Assess the client's 51 and 52 sounds for regularity.

Assess the client's apical pulse for a full minute.

Answer and Explanation

Correct Answer : A,D

A. Wait until the end of the physical assessment to reassess the radial pulse: If the radial pulse is irregular, it is important to reassess it to confirm irregularity. However, waiting until the end of the assessment is not recommended; it is better to reassess promptly.

B. Reassess the client's pedal pulse on the other foot: This is not related to assessing the regularity of the radial pulse.

C. Assess the client's 51 and 52 sounds for regularity: These terms are not standard in assessing pulse regularity; the focus should be on the apical pulse for an irregular radial pulse.

D. Assess the client's apical pulse for a full minute: The apical pulse should be assessed for a full minute to accurately determine the heart rate and rhythm, especially if the radial pulse is irregular.

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Correct Answer is D

Explanation

A. Stage III: This stage involves full-thickness tissue loss extending through the subcutaneous layer but does not typically present as a blister-like superficial wound.

B. Stage II: This stage is characterized by partial-thickness skin loss involving the epidermis and/or dermis, often presenting as a blister or superficial ulcer.

C. Stage I: Stage I pressure ulcers involve intact skin with non-blanchable redness, not a break in the skin or blister.

D. Stage IV: This stage involves full-thickness tissue loss with extensive destruction, potentially exposing bone or muscle, not a superficial blister.

A. Head and face B. Mouth and throat C. Mental status examination D. Ears

Correct Answer is A

Explanation

A. Head and face: Cranial nerve VII (facial nerve) controls the muscles of facial expression, so its motor function is assessed by examining the movement of the face, such as smiling, frowning, or raising eyebrows.

B. Mouth and throat: While cranial nerve VII does innervate some muscles involved in facial expressions that might affect the mouth, a more comprehensive assessment of its motor function occurs in the head and face region.

C. Mental status examination: This assesses cognitive functions rather than specific motor functions of cranial nerves.

D. Ears: The assessment of cranial nerve VII does not typically involve the ears.

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During a physical assessment, the nurse should implement which actions initially when determining if a client's radial pulse is irregular? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

The nurse notes a break in the skin, which appears blister-like, it looks superficial with loss up to the dermis layer. The nurse would interpret this finding as indicating which stage of

Correct Answer is D

Explanation

When performing a head-to-toe assessment, during which part would the nurse assess the motor function of cranial nerve VII?

Correct Answer is A

Explanation

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