In the assessment of peripheral pulses of a child, which pair should not be palpated simultaneously?
a. brachial pulses c. femoral pulses
b. carotid pulses d. popliteal pulses
B
To assess peripheral pulses, use the same finger to assess each pulse. The sensation of one finger pad versus another can be different. Use the finger pads to palpate each pair of peripheral pulses simultaneously, except for the carotid pulse. The carotid pulses should not be palpated together because excessive stimulation can elicit a vagal response and slow down the heart. Additionally, palpating both carotid pulses at the same time could also cut off circulation to the patient's head and brain.
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A nursing supervisor is seeking staff input while developing policies regarding violence prevention. A staff nurse says, "We have lots of threatening behaviors on our unit." What is the most important question for the supervisor to ask?
1. "Why is so much threatening behavior happening on your unit?" 2. "Why haven't you reported that?" 3. "Where do you work?" 4. "When you report threats to your manager, is action taken quickly?"
A client with alterations in the bladder is about to undergo a cystoscopy. The nurse should teach the client:
1. that burning on urination can occur for a couple of days post-procedure. 2. that the client should increase fluids before the test. 3. that bed rest is recommended for 2 days following the test. 4. to decrease fluid intake after the test.
A patient is unable to recognize or name familiar objects during her assessment. You would record this response as
a. agnosia. c. constructional apraxia. b. apraxia. d. visual amnesia.
Which behaviors by the nurse indicate a therapeutic relationship with children and families? (Select all that apply.)
a. Spending off-duty time with children and families b. Asking questions if families are not participating in the care c. Clarifying information for families d. Buying toys for a hospitalized child e. Learning about the family's religious preferences