When performing a focused cardiac assessment on a newly admitted client, the nurse notes a heave on the left side of the chest. What can a heave signify?
Enlargement of the heart ventricle
Turbulent blood flow
Persistently slow heart beat
Extreme pulse deficit
Coronary artery blockage
The Correct Answer is A
A. A heave (or lift) often indicates ventricular hypertrophy or enlargement, suggesting increased workload on the heart.
B. Turbulent blood flow may lead to murmurs but is not specifically associated with a heave.
C. A persistently slow heartbeat is referred to as bradycardia and does not correlate with a heave.
D. An extreme pulse deficit relates to discrepancies between heartbeats and palpable pulses but is not linked to a heave.
E. Coronary artery blockage would not directly produce a heave; it typically leads to ischemic changes.
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Correct Answer is E
Explanation
A. Providing care based on predetermined criteria may overlook individual client needs and cultural nuances.
B. Prioritizing hospital unit workflow may not align with the individual needs of clients.
C. Care aligned with professional healthcare values may not address the specific cultural values and preferences of diverse clients.
D. This approach may dismiss the client's autonomy and unique cultural context.
E. Honoring the client's differences and perspectives indicates a commitment to culturally responsive care, recognizing and respecting diverse backgrounds.
Correct Answer is E
Explanation
A. Music can be a soothing nonpharmacologic method to reduce pain and may help with relaxation, even for confused patients, as it typically doesn’t require cognitive engagement.
B. Aromatherapy is generally safe and may offer calming effects for older adults without relying heavily on cognitive processing.
C. Heat application is a physical pain relief method, and as long as safety precautions are taken, it can be used effectively in confused patients.
D. Distraction can be a beneficial technique for pain relief and is often effective without requiring cognitive engagement.
E. Guided Imagery should be avoided in confused older adults, as it relies on the patient's ability to follow instructions and visualize mental images, which can be challenging and potentially frustrating for someone with cognitive impairment.