when a nurse does a pulse he should note which of the following when a nurse does a pulse he should note which of the following
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1. When assessing a pulse, what should be noted?

Correct answer: Rate, quality, and fullness

Rationale: When assessing a pulse, it is important to note the rate (number of beats per minute), quality (regular or irregular), and fullness (thread and weak or full and bounding). These aspects provide crucial information about the patient's cardiovascular status. Regularity, as mentioned in option D, is not typically assessed during a pulse check and is not necessary for routine pulse assessment. Choice A is too limited as it overlooks important aspects beyond just the rate. Choice B improves by adding quality but still lacks the fullness aspect. Choice C is the most comprehensive and accurate as it includes all three essential aspects for a thorough pulse assessment.

2. Which of the following individuals is at the highest risk of experiencing intimate partner violence?

Correct answer: A 20-year-old woman who grew up with a psychologically abusive father

Rationale: Intimate partner violence is a serious issue encompassing physical, psychological, or sexual abuse within an intimate relationship. Individuals who have experienced psychological abuse in their upbringing are at a higher risk of becoming victims themselves due to the normalization of abusive behaviors. While factors such as age, mental health conditions, and social support can contribute to vulnerability, growing up in an abusive environment can significantly heighten the risk of intimate partner violence. The other options, such as recent divorce (A), unemployment (B), and schizophrenia diagnosis (D), do not directly correlate with the same level of increased risk associated with a history of psychological abuse.

3. A writer is admitted for the second time accompanied by his wife. He is demanding, arrogant, talks fast, and is hyperactive. Initially, the nurse should plan this for a manic client:

Correct answer: Set realistic limits to the client’s behavior

Rationale: For a manic client who is demanding, arrogant, talks fast, and is hyperactive, setting realistic limits to the client’s behavior is essential to ensure safety as manic clients may engage in injurious activities. A quiet environment and consistent, firm limits help to maintain control. While repeating verbal instructions may be necessary due to distractibility, it is not the priority compared to setting limits for safety. Allowing the client to express feelings is important, but only non-destructive methods of expression should be permitted. Assigning a staff member to be with the client at all times is not a realistic approach as it may not always be feasible or necessary for managing manic behavior effectively.

4. A nurse is caring for newborn infants in a nursery when a man enters the area to take his baby back to the room. The man does not have an identification bracelet, and the nurse does not recognize him. What is the next action of the nurse?

Correct answer: Ask the man to return to his room and bring an identification band

Rationale: The safety of infants in newborn nurseries is maintained by requiring parents to wear identification bracelets to identify themselves as the rightful parents. This practice minimizes the risk of mistakenly allowing an unauthorized individual to take a baby. In this scenario, since the nurse does not recognize the man and he lacks an identification bracelet, the appropriate action is to ask him to return to his room and bring the identification band. This step ensures the proper identity verification before allowing the man to take the baby. Calling security without first verifying the man's identity may escalate the situation unnecessarily. Checking the infant's chart alone does not confirm the man's identity. Allowing the man to take the baby without proper verification poses a safety risk to the infant.

5. Following hospitalization for congestive heart failure, a client is discharged. The nurse teaching the family suggests they encourage the client to rest frequently in which of the following positions?

Correct answer: High Fowler's

Rationale: The correct answer is High Fowler's. Sitting in a chair or resting in a bed in the high Fowler's position helps decrease the cardiac workload and facilitates breathing in clients with congestive heart failure. This position helps reduce venous return and increases lung expansion, improving oxygenation. The supine position (choice B) may lead to increased pressure on the heart and lungs, making it less suitable for these clients. The left lateral position (choice C) is not as effective as High Fowler's in reducing cardiac workload and improving breathing. Low Fowler's position (choice D) does not provide the same benefits as the High Fowler's position for clients with congestive heart failure.

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