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When assessing the temperature of newborns and children, the nurse decides to utilize a temporal artery thermometer. What is the rationale for the nurse's action?
- A. It is not affected by skin moisture.
- B. It has no risk of injury to patient or nurse.
- C. It reflects rapid changes in radiant temperature.
- D. It is accurate even when the forehead is covered with hair
Correct Answer: B
Rationale: Temporal artery thermometers are non-invasive, posing no injury risk (B), ideal for newborns and children. Moisture (A) can affect accuracy. Radiant changes (C) are less relevant. Hair (D) interferes. Choice B is correct, per pediatric safety standards.
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The patient is lying in bed under a ceiling fan. Which technique is the nurse using when the fan produces heat loss?
- A. Radiation
- B. Conduction
- C. Convection
- D. Evaporation
Correct Answer: C
Rationale: A ceiling fan moves air over the patient, causing heat loss via convection (C), where warm air around the body is replaced by cooler moving air. Radiation (A) involves heat emission without contact, not fan-driven. Conduction (B) requires direct contact (e.g., cold pack), not air movement. Evaporation (D) involves moisture loss, not primarily fan-related here. Choice C is correct because convection matches the mechanism of air circulation enhancing heat dissipation, a principle nurses apply in thermoregulation strategies to cool patients effectively in clinical settings.
The nurse is preparing to assess the blood pressure of a 3 year old. How should the nurse proceed?
- A. Use the diaphragm portion of the stethoscope to detect Korotkoff sounds.
- B. Obtain the reading before the child has a chance to 'settle down.'
- C. Choose the cuff that says 'Child' instead of 'Infant.'
- D. Explain the procedure to the child.
Correct Answer: D
Rationale: For a 3-year-old, explaining the procedure (D) reduces anxiety, improving cooperation. Diaphragm (A) is less effective than the bell for Korotkoff sounds. Pre-settling (B) risks agitation. Child cuff (C) is correct but secondary. Choice D is correct, per pediatric nursing communication strategies.
When taking the pulse of an infant, the nurse notices that the rate is 145 beats/min and the rhythm is regular. How should the nurse interpret this finding?
- A. This is normal for an infant.
- B. This is too fast for an infant.
- C. This is too slow for an infant.
- D. This is not a rate for an infant but for a toddler
Correct Answer: A
Rationale: Infant pulse ranges from 120-160 beats/min; 145 (A) is normal with regular rhythm. Too fast (B) or slow (C) misaligns with norms. Toddler rates (D) are lower (80-130). Choice A is correct, per pediatric vital sign standards.
The nurse is providing a blood pressure clinic for the community. Which group will the nurse most likely address?
- A. Non-Hispanic Caucasians
- B. European Americans
- C. African Americans
- D. Asian Americans
Correct Answer: C
Rationale: African Americans (C) have higher hypertension prevalence (e.g., AHA data), making them a priority for BP clinics. Other groups (A, B, D) have lower rates. Choice C is correct, reflecting public health focus on at-risk populations for cardiovascular screening.
The patient wants to monitor blood pressure at home and asks the nurse's advice about how to purchase a portable electronic blood pressure device. Which other information will the nurse share with the patient?
- A. You can apply the cuff in any manner.
- B. You will need to recalibrate the machine.
- C. You can move your arm during the reading.
- D. You will need to use a stethoscope properly.
Correct Answer: B
Rationale: Portable BP devices require recalibration (B) for accuracy, a key teaching point. Random cuff placement (A) or arm movement (C) skews readings. Stethoscopes (D) aren't needed for electronic devices. Choice B is correct, ensuring reliable home monitoring per nursing education.