The nurse is assessing an adult client's pulse. Which method will ...

[dmcintosh]

The nurse is assessing an adult client's pulse. Which method will is appropriate for the nurse to initially use?
 
  1. Monitoring for a full 2 minutes.
  2. Monitoring for 1 complete minute.
  3. Monitoring for 30 seconds and multiply by 2.
  4. Monitoring for 15 seconds and multiply by 4.

Question 2

The nurse educator is preparing an in-service on pain management for the staff. One of the staff nurses asks, What is the most important part of a pain assessment? Which response by the nurse educator is the most appropriate?
 
  1. Pain is only partially subjective and primarily a physiologic experience, so vital signs are the most important assessment.
  2. A client's response to pain is always based on the underlying cause, so the client's admitting diagnosis is important.
  3. Vital signs are not reliable indicators of acute pain, because only some clients are able to elicit a change in blood pressure or pulse rate.
  4. The response to pain is unique and based on numerous factors, which need to be assessed.

[14vl19]

Answer to Question 1

Correct Answer: 3

For the initial pulse assessment, the nurse may count the beats for 30 seconds and multiply by 2. It is not necessary for the nurse to count the pulse for 2 minutes, as heart rate is expressed in beats per minute. With any irregular pulse, the rate needs to be counted for 1 full minute Counting for 15 seconds and multiplying by 4 may not yield an accurate result, and therefore should not be used in assessing the rate.

Answer to Question 2

Correct Answer: 4
Pain is a subjective experience, and the response is unique to each individual. The factors that impact the response are numerous and include age, sex, culture, and developmental level, as well as previous experience with pain and health status. Vital signs are only a portion of the pain assessment. The nurse must consider many factors since pain is an individual experience and no two people experience pain in the same way. A patient's level of pain cannot be determined by his physiologic response only. Pain is unique to each person and may be experienced differently by clients with the same diagnosis. Vital signs can be indicators of pain. In the early stages of acute pain, the sympathetic nervous system is stimulated, causing increases in blood pressure, pulse, and respiratory rates.

[dmcintosh]

Thank you

[14vl19]

Happy to help you