The nurse finds a client's pulse to be very weak, but palpable. Documentation should note that this pulse is:
hypovolemic.
bradycardic.
deficient.
thready.
The Correct Answer is D
D. A "thready" pulse is weak and difficult to palpate. It feels like a fine thread or string under the fingertips and suggests poor cardiac output or decreased peripheral perfusion. A thready pulse is palpable but weak, indicating inadequate stroke volume with each heartbeat.
A. Hypovolemic refers to a state of decreased blood volume, which can lead to a weak and rapid pulse due to reduced blood flow through the arteries. However, it does not specifically describe the quality of the pulse that is palpable.
B. Bradycardia refers to a slow heart rate, typically below 60 beats per minute in adults. A bradycardic pulse may be slow but can still be strong or weak depending on the underlying cause. It does not specifically describe the quality of a weak but palpable pulse.
C. "Deficient" is not a commonly used term to describe the quality of a pulse. It does not provide specific information about the palpable nature or strength of the pulse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. This is the most appropriate goal for a client experiencing diarrhea. Diarrhea is characterized by loose or watery stools, and the goal of treatment is to restore normal stool consistency. This goal focuses on improving the symptoms and resolving the underlying cause of diarrhea, whether it's due to infection, dietary factors, or other reasons.
A. "Defecating regularly" does not necessarily imply improvement in diarrhea symptoms or resolution of the underlying cause. It is vague and does not provide a clear target related to diarrhea management.
B. Increasing ingestion of fruits may be beneficial for some individuals as fruits contain fiber and fluids that can help regulate bowel movements and maintain hydration. However, certain fruits high in fiber (e.g., apples, pears) may exacerbate diarrhea in some cases. This goal should be tailored based on the individual's tolerance and specific dietary needs.
C. This goal is not appropriate for managing diarrhea. Diarrhea leads to fluid loss and dehydration, so limiting fluid intake can worsen dehydration and electrolyte imbalances. Adequate fluid intake is crucial to replace lost fluids and maintain hydration during episodes of diarrhea.
Correct Answer is B
Explanation
B Leaning away from the client can convey disinterest, distraction, or a lack of engagement. It creates physical distance and may inhibit the client from feeling heard or valued. Thus, leaning away from the client can be a barrier to active listening as it diminishes the nurse's ability to fully attend to and understand the client's message.
A. An open posture, where the nurse's body is facing the client with arms uncrossed and relaxed, signals openness and receptivity. It encourages communication and shows the client that the nurse is engaged and attentive. Therefore, an open posture promotes active listening rather than serving as a barrier.
C. Eye contact is essential for effective communication and active listening. It demonstrates attentiveness, interest, and respect. Establishing eye contact helps the nurse to connect with the client and encourages them to continue sharing their thoughts and feelings. Therefore, eye contact supports active listening rather than hindering it.
D. Sitting squarely facing the client promotes engagement and shows that the nurse is focused on the client. It facilitates direct communication and helps the nurse to observe the client's nonverbal cues effectively. This posture encourages open dialogue and supports active listening rather than acting as a barrier.
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