The practical nurse (PN) palpates a client's radial pulse and notes that the pulse disappears when light pressure is applied.
How should the PN document this finding?
Thready pulse volume
Missing pulse.
Light pressure applied to pulse
Pulse skips beats
The Correct Answer is A
A thready pulse is a weak and rapid pulse that is easily obliterated by light pressure. It indicates poor blood flow and perfusion, and may be caused by conditions such as shock, dehydration, or hemorrhage.
The other options are not correct because:
- A missing pulse is a pulse that is absent or cannot be detected, even with firm pressure. It indicates a complete blockage of blood flow, and may be caused by conditions such as arterial occlusion, embolism, or trauma.
- Light pressure applied to pulse is not a documentation of the pulse quality, but a description of the technique used to palpate the pulse.
- Pulse skips beats is a documentation of an irregular pulse rhythm, not a pulse volume. It indicates that the heart beats are unevenly spaced, and may be caused by conditions such as arrhythmia, stress, or caffeine intake.
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Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B: Children need time to actively explore their environment. Choice A rationale:
Playpens do provide a sense of security for the child, but confining the child solely to the playpen might hinder their developmental needs. While it is essential to have a safe space for a toddler, children also require opportunities to explore and engage with their environment actively.
Choice B rationale:
The practical nurse (PN) should use this rationale when responding to the parent. Children, especially toddlers, learn and develop crucial skills through active exploration of their environment. Being confined to a playpen for extended periods may limit their opportunities for learning, hinder their physical development, and restrict social interaction, which are essential aspects of their growth.
Choice C rationale:
While playpens can provide a safe environment for a toddler when used appropriately and under supervision, keeping the child confined for the sole purpose of preventing dirtiness is not recommended. Overusing playpens can hinder a child's natural curiosity and desire to explore, potentially affecting their overall development.
Choice D rationale:
While over-concern about appearance can be harmful in some contexts, it is not directly related to the child being kept in a playpen to avoid getting dirty. The primary concern here is about providing the child with adequate opportunities for exploration, growth, and development, rather than focusing solely on appearance.
Correct Answer is B
Explanation
The PN should not prioritize bringing a glucometer to the room in this situation. The client's unresponsiveness indicates a potential medical emergency that requires immediate action, and checking blood glucose levels is not the primary concern at this moment.
Choice C rationale:
Feeling for a carotid pulse is an essential step in assessing the client's circulation. However, it is not the first priority when the client is unresponsive. The PN should focus on obtaining emergency help first to ensure timely intervention.
Choice D rationale:
Checking the blood pressure can provide valuable information about the client's condition, but it is not the most critical step when dealing with an unresponsive client. Promptly seeking emergency assistance is more important to address the immediate concern.
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