The nurse needs to determine the apical pulse of a client from a different culture. In order to show appropriate sensitivity to the client, the nurse should take which action?
1. Explain the procedure, then wait for permission to continue.
2. Explain to the client what will occur during the assessment.
3. Ask the client to stay quiet because the nurse will be listening to the heart.
4. Take the baseline vital signs, then determine if cardiac auscultation is necessary.
Correct Answer: 1
Rationale 1: Cardiac assessment requires that the nurse move into the client's intimate space. Before beginning this, the nurse should explain the procedure and then await permission to continue.
Rationale 2: Explaining the assessment only while performing the procedure and not before is likely to cause the client anxiety and thus negatively affect the assessment values.
Rationale 3: This option is not addressing the sensitivity issues appropriate for this scenario.
Rationale 4: This option is not addressing the sensitivity issues appropriate for this scenario.
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