A nurse assesses a patient's dorsalis pedis pulse. The pulse is not palpable when light pressure is applied. How should the nurse document this finding?
a. Weak pulse
b. Normal pulse
c. Thready pulse
d. Bounding pulse
ANS: A
A thready pulse is difficult to feel and is not palpable when only slight pressure is applied. A weak pulse is somewhat stronger than a thready pulse but not palpable when light pressure is applied. A normal pulse is easily felt but not palpable when moderate pressure is applied. A bounding pulse feels full and springlike even under moderate pressure.
You might also like to view...
The patient was admitted with the diagnosis of a stroke. The patient experiences dysphagia and right side paralysis and needs assistance with activities of daily living (ADLs)
The nurse caring for the patient has assigned the task of feeding the patient to the new nursing assistant personnel (NAP), and is concerned about aspiration. The nurse knows additional teaching is necessary when NAP states which of the following? a. "I will remind the patient to tilt the head backward when drinking fluids." b. "Thin fluids like water and fruit juice will need to be thickened." c. "I need to watch for pocketing food as I feed the patient." d. "It will take much longer to feed the patient than it did before the stroke."
Which assessment data obtained by the nurse during the health history portion of the assessment process support the current diagnosis of Duchenne muscular dystrophy (MD) for an 18-month-old child?
1. Infant was postmature by almost 2 weeks. 2. The child seems very muscular. 3. The child walked early and without support at 10 months. 4. The child's older sister developed scoliosis in the fourth grade.
A client is agitated, using profanity, and verbally threatening other clients. Based on these be-haviors, the nurse should initially plan to:
1. Speak to the physician about reevaluating the client's medications 2. Initiate verbal intervention and take the client to his or her room 3. Secure enough staff members to place the client in seclusion 4. Speak with the other clients about their feelings
A child who has beta-thalassemia is receiving numerous blood transfusions and deferoxamine (Desferal) therapy. The parents ask how the deferoxamine will help their child. Which response by the nurse is accurate?
1. "It stimulates red blood cell production." 2. "It prevents iron overload." 3. "It provides vitamin supplementation." 4. "It decreases the risk of transfusion reactions."