The nurse is preparing to measure the temperature of a client with an endotracheal
tube. Which method of temperature measurement should the nurse use for this client?
Tympanic
Rectal
Axillary
Oral
Give this one a try later!
, Tympanic
The tympanic temperature measures a client's core body temperature
quickly and accurately. This method is the most comfortable and least
invasive for the client. Rectal temperatures are used in clients who are
comatose, confused, or unable to close their mouth. However, in these
situations a tympanic temperature could be used and is less invasive. An
oral temperature should not be used on this client because of the
endotracheal tube and the inability to close the mouth. The axillary
temperature is the least accurate of the temperature methods and isn't
indicated since a tympanic device is available.
The nurse is assessing the respiratory rate of a 35-year-old male client. Which of the
following would indicate a normal finding for this client?
Respiratory rate of 30 to 80 per minute
Respiratory rate of 20 to 40 per minute
Respiratory rate of 15 to 20 per minute
Respiratory rate of 8 to 10 per minute
Give this one a try later!
Respiratory rate of 15 to 20 per minute
The normal respiratory rate of adults is between 15 and 20 per minute.
Respiratory rates of 30-80 per minute are the normal range for newborns.
Respiratory rates of 20-40 per minute are considered normal for ages up to
1 year. A respiratory rate of 8-10 per minute is abnormally slow respirations
for any age group.
A client tells the nurse, "It's okay that I'm 20 pounds overweight. Everyone in my family
is much fatter." Which of the following would be the best response for the nurse to
make at this time?
"Being overweight contributes to the development of diabetes."
"Do your family members have health problems related to being overweight?"
,"Being the lightest in your family must make you feel good."
"How do you feel about being 20 pounds overweight?"
Give this one a try later!
"How do you feel about being 20 pounds overweight?"
The client is overweight and is attempting to rationalize it by comparing
herself with other family members. The fact is, the client is overweight, and
the nurse needs more information on the client's feelings about this fact
before educating the client on the risks of being overweight and obtaining
family history.
During a health care visit, the nurse learns that a client has had some degree of pain
for years yet has never sought medical intervention for the pain. The nurse realizes
that one explanation for this might be:
The client is practicing pain-reducing interventions.
The client has a history of substance abuse.
The client doesn't really have pain.
The client has become accustomed to having pain.
Give this one a try later!
The client has become accustomed to having pain.
Previous experiences with pain affect the way an individual responds to
pain. This client's history of having pain for years may explain why he is able
to live with the pain. There is no provided history of pain-reducing
interventions or substance abuse. Assuming the client doesn't have pain is a
judgment on the nurse's part and a nontherapeutic assessment.
The nurse is measuring an adult client's blood pressure and hears Korotkoff sounds.
Which sound should the nurse recognize as being the diastolic measurement for this
client?
, Phase 1
Phase 3
Phase 4
Phase 5
Give this one a try later!
Phase 5
In adults, the diastolic pressure (Phase 5) is the point at which the sounds
become inaudible. Phase 1 sounds are the first sounds heard and signify
systolic blood pressure. Phase 3 is the period in which the sounds are
louder. Phase 2 is the period during which the sounds are softer and
longer. Phase 4 is the period during which the sounds become muffled.
A client with chronic back pain has been prescribed a tricyclic antidepressant
medication. The nurse realizes that this medication will:
Do nothing for the client's pain.
Cause the client to sleep through most of the pain.
Act as a placebo for the client's pain.
Increase the modulation phase of the pain cycle.
Give this one a try later!
Increase the modulation phase of the pain cycle.
Individuals with chronic pain may be prescribed tricyclic antidepressants to
inhibit the reuptake of norepinephrine and serotonin. This action increases
the modulation phase that helps inhibit painful ascending stimuli. A
medication would not be prescribed if it were not thought to be effective.
When treating pain, the primary effect of the medication is not sleep.
A client describes sudden headaches that last a few minutes and are associated with
stress. The client experiences nasal congestion and watery eyes associated with the
headaches. The nurse realizes that this client is describing:
tube. Which method of temperature measurement should the nurse use for this client?
Tympanic
Rectal
Axillary
Oral
Give this one a try later!
, Tympanic
The tympanic temperature measures a client's core body temperature
quickly and accurately. This method is the most comfortable and least
invasive for the client. Rectal temperatures are used in clients who are
comatose, confused, or unable to close their mouth. However, in these
situations a tympanic temperature could be used and is less invasive. An
oral temperature should not be used on this client because of the
endotracheal tube and the inability to close the mouth. The axillary
temperature is the least accurate of the temperature methods and isn't
indicated since a tympanic device is available.
The nurse is assessing the respiratory rate of a 35-year-old male client. Which of the
following would indicate a normal finding for this client?
Respiratory rate of 30 to 80 per minute
Respiratory rate of 20 to 40 per minute
Respiratory rate of 15 to 20 per minute
Respiratory rate of 8 to 10 per minute
Give this one a try later!
Respiratory rate of 15 to 20 per minute
The normal respiratory rate of adults is between 15 and 20 per minute.
Respiratory rates of 30-80 per minute are the normal range for newborns.
Respiratory rates of 20-40 per minute are considered normal for ages up to
1 year. A respiratory rate of 8-10 per minute is abnormally slow respirations
for any age group.
A client tells the nurse, "It's okay that I'm 20 pounds overweight. Everyone in my family
is much fatter." Which of the following would be the best response for the nurse to
make at this time?
"Being overweight contributes to the development of diabetes."
"Do your family members have health problems related to being overweight?"
,"Being the lightest in your family must make you feel good."
"How do you feel about being 20 pounds overweight?"
Give this one a try later!
"How do you feel about being 20 pounds overweight?"
The client is overweight and is attempting to rationalize it by comparing
herself with other family members. The fact is, the client is overweight, and
the nurse needs more information on the client's feelings about this fact
before educating the client on the risks of being overweight and obtaining
family history.
During a health care visit, the nurse learns that a client has had some degree of pain
for years yet has never sought medical intervention for the pain. The nurse realizes
that one explanation for this might be:
The client is practicing pain-reducing interventions.
The client has a history of substance abuse.
The client doesn't really have pain.
The client has become accustomed to having pain.
Give this one a try later!
The client has become accustomed to having pain.
Previous experiences with pain affect the way an individual responds to
pain. This client's history of having pain for years may explain why he is able
to live with the pain. There is no provided history of pain-reducing
interventions or substance abuse. Assuming the client doesn't have pain is a
judgment on the nurse's part and a nontherapeutic assessment.
The nurse is measuring an adult client's blood pressure and hears Korotkoff sounds.
Which sound should the nurse recognize as being the diastolic measurement for this
client?
, Phase 1
Phase 3
Phase 4
Phase 5
Give this one a try later!
Phase 5
In adults, the diastolic pressure (Phase 5) is the point at which the sounds
become inaudible. Phase 1 sounds are the first sounds heard and signify
systolic blood pressure. Phase 3 is the period in which the sounds are
louder. Phase 2 is the period during which the sounds are softer and
longer. Phase 4 is the period during which the sounds become muffled.
A client with chronic back pain has been prescribed a tricyclic antidepressant
medication. The nurse realizes that this medication will:
Do nothing for the client's pain.
Cause the client to sleep through most of the pain.
Act as a placebo for the client's pain.
Increase the modulation phase of the pain cycle.
Give this one a try later!
Increase the modulation phase of the pain cycle.
Individuals with chronic pain may be prescribed tricyclic antidepressants to
inhibit the reuptake of norepinephrine and serotonin. This action increases
the modulation phase that helps inhibit painful ascending stimuli. A
medication would not be prescribed if it were not thought to be effective.
When treating pain, the primary effect of the medication is not sleep.
A client describes sudden headaches that last a few minutes and are associated with
stress. The client experiences nasal congestion and watery eyes associated with the
headaches. The nurse realizes that this client is describing:
