Physical Examination and Health Assessment 8th Edition 0323510809
Chapter 10: Vital Signs Jarvis: Physical Examination and Health Assessment, 8th Edition MULTIPLE CHOICE 1. The nurse should measure rectal temperatures in which of these patients? a. Older adult b. Comatose adult c. School-age child d. Patient receiving oxygen by nasal cannula ANS: B
Rectal temperatures should be taken when the other routes are impractical, such as for comatose or confused people, for those in shock, or for those who cannot close the mouth because of breathing or oxygen tubes, a wired mandible, or other facial dysfunctions. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 2. 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 should the nurse include? a. “Measuring temperature using the TMT is inexpensive.” b. “The rapid measurement of the TMT is useful for uncooperative younger children.” c. “Using the TMT is the most accurate method for measuring body temperature in newborn infants.” d. “Studies strongly support the use of the TMT in children under the age 6 years.” ANS: B
The TMT is useful for young children who may not cooperate for oral temperatures and fear rectal temperatures. However, the use of a TMT with newborn infants and young children is conflicting. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 3. When assessing an older adult, the nurse should recognize that which vital sign changes occur
with aging? a. Increase in pulse rate b. Widened pulse pressure c. Increase in body temperature d. Decrease in diastolic blood pressure ANS: B
With aging, the nurse keeps in mind that the systolic blood pressure increases, leading to widened pulse pressure. With many older people, both the systolic and diastolic pressures increase. The pulse rate and temperature do not increase with aging. However, both the systolic and diastolic pressures increase in many older adults.
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