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 D

Explanation

A. A hematoma refers to a collection of blood outside of blood vessels, typically resulting in a bruise or swelling. The description of round, flat, pinpoint red spots does not suggest this type of injury.
B. Vesicles are small fluid-filled blisters, which do not match the description of the pinpoint red spots. Vesicles would be more elevated and contain fluid.
C. Ecchymosis refers to a bruise, or large, irregular areas of discoloration caused by blood leaking into the tissues. The description of pinpoint red spots suggests petechiae, not ecchymosis.
D. Petechiae are small, round, flat, pinpoint red or purple spots that occur when small blood vessels (capillaries) break under the skin. This is the most appropriate description for the observed finding, particularly in the context of trauma from intimate partner violence.

A. Document this finding in the medical record. B. Ask if the client recently received any antibiotics. C. Ask the client about use of irritating chemical agents. D. Schedule an appointment with a dermatologist.

Correct Answer is A

Explanation

A. Documenting the finding is important to ensure proper record-keeping, especially in clients with dark pigmented skin, where some variations in skin tone may be normal.
B. Asking about antibiotics is unnecessary unless there's suspicion of a drug-induced reaction or side effect.
C. While use of irritating chemicals could cause changes, this scenario does not directly suggest that as the cause.
D. Referral to a dermatologist is not required without further investigation to determine if the discoloration is concerning.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing a head-to-toe physical examination on a known victim of intimate partner violence. The visual exam reveals several round, flat, pinpoint, red spots. How should the nurse document this finding?

Correct Answer is D

Explanation

The nurse is performing oral inspection of a client with dark pigmented skin. The nurse observes a patchy discoloration of the buccal mucosa. Which action should the nurse take?

Correct Answer is A

Explanation

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