What findings does the nurse expect when assessing the cardiovascular system of a healthy adult? Select the 3 correct answers. (Select All that Apply.)
Pulse of smooth contour with 2+ amplitude
Heart rate of 62 beats/min
S1 and S2 present with regular rhythm
Mild, pedal edema
Correct Answer : A,B,C
A. Pulse of smooth contour with 2+ amplitude. A normal pulse should have a smooth upstroke and downstroke with a moderate (2+) amplitude, indicating adequate blood flow and cardiac function.
B. Heart rate of 62 beats/min. A normal resting heart rate for a healthy adult range from 60 to 100 beats per minute. A heart rate of 62 bpm is within this normal range.
C. S1 and S2 present with regular rhythm. The first (S1) and second (S2) heart sounds should be audible and regular, indicating normal closure of the heart valves and a steady cardiac rhythm.
D. Mild, pedal edema. Pedal edema is not a normal finding in a healthy adult and may indicate fluid retention or cardiovascular issues such as heart failure or venous insufficiency.
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Related Questions
Correct Answer is C
Explanation
A. Errors by the nurse assistant in measuring temperature. While improper technique can lead to inaccurate readings, consistent temperature fluctuations in a head injury patient are more likely due to hypothalamic dysfunction.
B. Increased vasodilatation of the superficial vessels contributing to excess heat losses. Vasodilation can play a role in heat loss, but it does not fully explain difficulty maintaining body temperature, which is primarily regulated by the hypothalamus.
C. The client's head injury causing interference with the function of the hypothalamus. The hypothalamus regulates body temperature, and a severe head injury can disrupt this function, leading to temperature instability (neurogenic fever or hypothermia) despite the absence of infection.
D. Choosing the wrong time of day to obtain vital signs. While body temperature naturally fluctuates throughout the day, major instability in temperature regulation is not due to the timing of measurement but rather an issue with the hypothalamus.
Correct Answer is A
Explanation
A. Carotid. The carotid arteries supply blood to the brain, and compressing both simultaneously can reduce cerebral blood flow, potentially causing dizziness, syncope, or loss of consciousness. Therefore, carotid pulses should be assessed one at a time.
B. Radial. The radial pulse can be safely assessed bilaterally at the same time since it does not affect central circulation or brain perfusion.
C. Brachial. The brachial pulse can also be assessed bilaterally without risk, as it does not impact blood flow to critical organs like the brain.
D. Femoral. The femoral pulse can be checked simultaneously on both sides to assess circulation and perfusion, especially in cases of suspected arterial insufficiency.
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