The nurse needs to determine the apical pulse of a client from a ...

[Hungry!]

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.

Question 2

The nurse is teaching a client from a culture that is present oriented about a dressing change that should be performed twice a day. How should the nurse address the cultural issue?
 
  1. Allow the client to select the times the dressing will be changed.
  2. Instruct the client to change the dressing after breakfast and before going to bed.
  3. Explain that the client should complete the dressing change at 10 AM and 4 PM.
  4. Suggest that the dressing change can be performed whenever the client chooses, as long as it gets done twice daily.

[Pariscourtney]

Answer to Question 1

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.

Answer to Question 2

Correct Answer: 2
Rationale 1: This option does not assure the dressing changes will occur as prescribed.
Rationale 2: For clients who are present oriented, it is important to avoid fixed schedules. The nurse can offer a time range for activities and treatments, such as in the morning or after breakfast, and in the evening or before going to bed. This would fit better with the client who isn't focused on times of the day, such as 10 AM and 4 PM, but will provide for a dressing change twice daily.
Rationale 3: This option is not likely to be followed by a client who is present oriented.
Rationale 4: This option does not comply with the intended order for the dressing changes.

[Hungry!]

Excellent

[ricroger]

Gracias!