Nokea
A patient has a head injury and damages the hypothalamus. Which vital sign will the nurse monitor most closely?
- A. Pulse
- B. Temperature
- C. Respirations
- D. Blood pressure
Correct Answer: B
Rationale: The hypothalamus regulates body temperature, so damage from a head injury disrupts thermoregulation, potentially causing hypo- or hyperthermia. Monitoring temperature (B) is critical to detect these shifts, which can indicate injury severity or complications like fever from inflammation. Pulse (A) reflects cardiac response but isn't directly hypothalamic. Respirations (C) may change secondary to brain injury but aren't primarily hypothalamic. Blood pressure (D) can fluctuate with intracranial pressure, yet temperature is the most directly affected vital sign here. Choice B is correct as it aligns with the hypothalamus's role in maintaining thermal homeostasis, a priority in neuro nursing to prevent further brain damage or systemic issues.
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The nurse needs to take the temperature of a patient who had a cardiac arrest. Which route will the nurse use?
- A. Oral
- B. Rectal
- C. Tympanic
- D. Temporal
Correct Answer: C
Rationale: Post-cardiac arrest, tympanic (C) provides a quick, non-invasive core temperature estimate, critical for monitoring hypothermia or hyperthermia in resuscitation. Oral (A) risks inaccuracy post-arrest. Rectal (B) is invasive and slow. Temporal (D) is less reliable in emergencies. Choice C is correct, aligning with ACLS emphasis on rapid, safe temperature assessment.
What is the primary purpose of pulse assessment?
- A. Assessing changes in blood pressure
- B. Assessing changes in body temperature
- C. Assessing changes in cardiac status
- D. Assessing changes in respiratory status
Correct Answer: C
Rationale: Pulse assessment primarily evaluates cardiac status (C), reflecting heart rate and rhythm, key indicators of cardiovascular function. Blood pressure (A) relates but requires a cuff. Temperature (B) isn't pulse-related. Respiratory status (D) is secondary. Choice C is correct, per nursing fundamentals, as pulse directly monitors heart performance, guiding cardiac care.
The nurse needs to increase heat conservation in a newborn. Which action will the nurse take?
- A. Apply just a diaper.
- B. Double the clothing.
- C. Place a cap on their heads.
- D. Increase room temperature to 90 degrees.
Correct Answer: C
Rationale: Newborns lose heat rapidly, especially from the head, due to a large surface area and limited thermoregulation. Placing a cap (C) conserves heat by covering this key area, a standard neonatal practice. A diaper alone (A) offers minimal coverage, increasing heat loss. Doubling clothing (B) helps but is less effective than a cap for head protection. Raising the room to 90?°F (D) risks overheating. Choice C is correct, supported by pediatric guidelines (e.g., AAP) emphasizing head coverage to maintain newborn temperature stability.
A nurse is caring for a group of patients on a medical-surgical unit. Which patient will the nurse assess first?
- A. A 17-year-old male who has just returned from outside 'for a smoke' who needs a temperature taken.
- B. A 20-year-old male postoperative patient whose blood pressure went from 128/70 to 100/60.
- C. A 27-year-old male patient reporting pain whose blood pressure went from 124/70 to 130/74.
- D. An 87-year-old male suspected of hypothermia whose temperature is below normal.
Correct Answer: B
Rationale: A postoperative BP drop from 128/70 to 100/60 (B) indicates potential shock or bleeding, a priority. Smoking (A) or pain with stable BP (C) is less urgent. Hypothermia (D) needs attention but lacks acuity data. Choice B is correct, per triage urgency in surgical care.
The patient requires routine temperature assessment but is confused, easily agitated, and has a history of seizures. Which route will the nurse use to obtain the patient's temperature?
- A. Oral
- B. Rectal
- C. Axillary
- D. Tympanic
Correct Answer: D
Rationale: For a confused, agitated patient with seizures, tympanic (D) is safest and fastest, avoiding oral risks (biting) or rectal invasiveness (agitation, seizure risk). Oral (A) is unreliable with agitation. Rectal (B) risks injury or vagal stimulation. Axillary (C) is slow and less accurate. Choice D is correct, per nursing safety protocols, balancing accuracy and patient stability.