Nokea
The nurse is teaching a student nurse about the different types of thermometers. When teaching the student about the advantages of the tympanic membrane thermometer (TMT), which statement would the nurse include?
- A. "Measuring temperature using the TMT is cost-effective."?
- B. "The rapid measurement of the TMT is beneficial for uncooperative younger children."?
- C. "TMT is not recommended for measuring core body temperature in newborn infants."?
- D. "TMT is not the preferred method for measuring body temperature in patients with otitis media."?
Correct Answer: B
Rationale: The correct answer is "The rapid measurement of the TMT is beneficial for uncooperative younger children." TMT is ideal for young children who may not cooperate for oral temperatures or fear rectal temperatures. However, using TMT for newborn infants is not recommended due to inconsistencies in results. Measuring temperature with TMT is not necessarily cost-effective. The most accurate method for measuring core temperature is through rectal temperatures. TMT may not be the preferred method for patients with otitis media due to potential inaccuracies caused by fluid behind the tympanic membrane.
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When assessing a patient's pulse, which of the following characteristics would the nurse also notice?
- A. Force
- B. Pallor
- C. Capillary refill time
- D. Timing in the cardiac cycle
Correct Answer: A
Rationale: When assessing a patient's pulse, the nurse should observe characteristics such as rate, rhythm, and force. Force refers to the strength or amplitude of the pulse, which provides important information about cardiac output. Pallor is the paleness of the skin and is not directly related to pulse assessment. Capillary refill time is used to assess peripheral perfusion and is not specifically part of pulse assessment. Timing in the cardiac cycle is a broader concept and not a characteristic directly assessed during a pulse examination. Therefore, choice A, 'Force,' is the correct answer as it aligns with the standard parameters evaluated during pulse assessment.
During an examination, the nurse notices that a female patient has a round "moon"? face, central trunk obesity, and a cervical hump. Her skin is fragile with bruises. The nurse determines that the patient likely has which condition?
- A. Gigantism
- B. Acromegaly
- C. Cushing syndrome
- D. Marfan syndrome
Correct Answer: C
Rationale: Cushing syndrome is characterized by weight gain and edema with central trunk and cervical obesity (buffalo hump) and a round, plethoric face (moon face). Excessive catabolism in Cushing syndrome causes muscle wasting, weakness, thin arms and legs, reduced height, and thin, fragile skin with purple abdominal striae, bruising, and acne. Gigantism is characterized by increased height and weight and delayed sexual development, which are not present in the patient. Acromegaly results from excessive growth hormone secretion in adulthood, leading to bone overgrowth in specific areas like the face, head, hands, and feet. Marfan syndrome is an inherited connective tissue disorder characterized by a tall, thin stature and distinct features not seen in this patient. The combination of signs described in the question aligns with the clinical presentation of Cushing syndrome.
What is the correct action regarding thigh pressure when comparing it to arm pressure in an adolescent with high blood pressure?
- A. The popliteal artery should be auscultated to obtain thigh pressure.
- B. The best position to measure thigh pressure is the prone position.
- C. If the blood pressure in the arm is high in an adolescent, then it should be compared with the thigh pressure.
- D. Thigh pressure is generally higher than arm pressure due to the proximity to the heart and the size of the popliteal vessels.
Correct Answer: C
Rationale: When blood pressure measured in the arm is significantly elevated, especially in adolescents and young adults, it is crucial to compare it with thigh pressure to assess for coarctation of the aorta. The popliteal artery, not the femoral artery, should be auscultated for the thigh pressure reading as the femoral artery is closer to the placement of the blood pressure cuff. Generally, thigh pressure is higher than arm pressure; however, if there is coarctation of the artery, arm pressures can be higher than thigh pressures. The preferred position for measuring thigh pressure is the prone position, not supine, with the knee slightly bent to facilitate accurate readings.
A triage nurse has four clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first?
- A. A 2-month-old infant with a history of rolling off the bed and having a bulging fontanelle with crying
- B. A teenager who suffered singed facial hair while camping
- C. An elderly client with complaints of frequent liquid brown-colored stools
- D. A middle-aged client with intermittent pain behind the right scapula
Correct Answer: B
Rationale: The correct answer is the teenager who suffered singed facial hair while camping. This client is in the greatest danger with a potential risk of respiratory distress. Singed facial hair indicates exposure to heat or fire in close range, which could have caused serious damage to the interior of the lungs. It's crucial to prioritize this client as the interior lining of the lungs has no nerve fibers, so swelling may not be immediately noticeable. The other choices, while concerning, do not present an immediate life-threatening situation. The infant's condition may be serious but does not pose an immediate danger of respiratory distress. The elderly client's symptoms could indicate gastrointestinal issues, which are important but not as urgent as potential respiratory compromise. The middle-aged client's pain behind the right scapula, while uncomfortable, does not indicate an acute life-threatening condition requiring immediate attention.
The nurse is assessing an 8-year-old child whose growth rate measures below the third percentile for a child his age. He appears significantly younger than his stated age and is chubby with infantile facial features. Which condition does this child likely have?
- A. Acromegaly
- B. Marfan syndrome
- C. Hypopituitary dwarfism
- D. Achondroplastic dwarfism
Correct Answer: C
Rationale: Hypopituitary dwarfism is caused by a deficiency in growth hormone in childhood and results in a retardation of growth below the third percentile, delayed puberty, and other problems. The child's appearance fits this description. Achondroplastic dwarfism is a genetic disorder resulting in characteristic deformities; Marfan syndrome is an inherited connective tissue disorder characterized by a tall, thin stature and other features. Acromegaly is the result of excessive secretion of growth hormone in adulthood which causes overgrowth of bone in the face, head, hands, and feet.