When assessing an older adult client with a history of cardiovascular disease, dyspnea, and peripheral edema, which method is best for the nurse to use to assess the client's pulse rate?

Palpate the radial pulses in both arms for a deficit.

Use the stethoscope to listen over the carotid artery.

Feel the volume of the dorsalis pedis and posterior tibialis pulses.

Auscultate the apical pulse at the point of maximal impulse.

Answer and Explanation

The Correct Answer is D

A.   Palpating the radial pulses might not detect irregularities in pulse rate or rhythm as effectively as auscultation at the apical site.
B.   Listening over the carotid artery may be useful in certain situations but is not the preferred method for assessing overall pulse rate.
C.   Feeling the dorsalis pedis and posterior tibialis pulses provides information about peripheral circulation but does not assess the overall heart rate.
D.   Auscultating the apical pulse is the most accurate method to assess the pulse rate, especially in clients with cardiovascular disease, as it provides direct measurement of heart activity.

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Correct Answer is C

Explanation

A. Alcohol or drug abuse screening may be important but does not directly assess functional ability.
B. Medication side effects can impact functionality, but ADLs are a direct measure of independence.
C. Assessing a client's ability to perform activities of daily living (ADLs) is crucial for determining their functional status and whether they can live independently or need assistance.
D. Long-term memory evaluation is less important than assessing the client's ability to perform daily tasks.

A. Increased risk for falling. B. Expected results for an older adult. C. Need for a walker to aid in ambulation. D. Likely onset of Parkinson's disease.

Correct Answer is A

Explanation

A. A Tinetti balance score of 12 and a gait score of 8 are indicative of an increased risk for falls. A total score below 19 suggests significant fall risk and a need for interventions to prevent injury.
B. While the results may reflect some age-related changes, they are lower than expected for a healthy older adult without significant mobility issues.
C. The results suggest an increased risk for falls but do not automatically indicate a need for a walker. Further assessment of functional capacity is needed.
D. The results do not specifically indicate Parkinson's disease, although balance and gait issues may be present in such conditions. Parkinson’s diagnosis would require additional motor and neurological assessments.

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When assessing an older adult client with a history of cardiovascular disease, dyspnea, and peripheral edema, which method is best for the nurse to use to assess the client's pulse rate?

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Naxlex Comprehensive Predictor Exams

An older adult client is being evaluated for admission to an assisted living facility. During the health assessment, the nurse implements which technique to determine the client's ability to reside in this environment?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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