The nurse is assessing vital signs on a client admitted to the medical-surgical unit. What is the correct technique for assessing the radial pulse?

The use of two middle fingers lightly applied to area along the thumb side of the wrist.

Application of firm pressure on the wrist area along the side of the fifth digit.

Application of the bell of the stethoscope to the antecubital area of the upper extremity.

Use of the thumb and index finger to obliterate the area along the thumb side of the wrist.

Answer and Explanation

The Correct Answer is A

A. Using two middle fingers lightly applied to the thumb side of the wrist is correct. This technique ensures accurate detection of the radial pulse without excessive pressure, which could occlude the artery.
B. Firm pressure on the wrist along the fifth digit (ulnar side) is incorrect because the radial pulse is located on the thumb side of the wrist, not the ulnar side.
C. Using the bell of the stethoscope in the antecubital area is incorrect because this technique is used for blood pressure assessment, not radial pulse assessment.
D. Using the thumb and index finger to obliterate the pulse is incorrect because the thumb has its own pulse, which may lead to inaccurate readings.

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Correct Answer is A

Explanation

A. The client's ability to change position is correct. The Braden Scale assesses sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Limited mobility increases the risk for pressure injuries.
B. A history of integumentary disorders is not part of the Braden Scale assessment. The scale focuses on current risk factors rather than past dermatologic conditions.
C. Skin pigmentation is not a factor in pressure ulcer risk assessment. However, in clients with darker skin, early signs of pressure injuries may be harder to detect due to lack of visible blanching.
D. Medications are not directly included in the Braden Scale. While some medications (e.g., steroids) can increase pressure injury risk, the Braden Scale does not specifically assess them.

A. Carbohydrate deficiency B. Vitamin B12 deficiency C. Protein deficiency D. Vitamin A deficiency

Correct Answer is C

Explanation

A. Carbohydrate deficiency can lead to low energy levels and weight loss, but it is not primarily associated with edema, brittle nails, or dry hair.
B. Vitamin B12 deficiency can cause neurological symptoms and anemia, but it does not typically lead to edema or brittle nails.
C. Protein deficiency is correct because it can cause muscle wasting, poor wound healing, thin and dry hair, brittle nails, and edema due to low albumin levels.
D. Vitamin A deficiency is primarily linked to vision problems, dry skin, and an increased risk of infections but does not typically cause edema or brittle nails.

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The nurse is assessing vital signs on a client admitted to the medical-surgical unit. What is the correct technique for assessing the radial pulse?

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A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale?

Correct Answer is A

Explanation

A client has come into the clinic with complaints of anorexia for one month with a noted 20-pound weight loss in the past six weeks. The nurse notes mild edema to the lower extremities, thin, dry hair, and brittle nails. What deficiency are these findings most likely related to?

Correct Answer is C

Explanation

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