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Questions and Answers
A patient has a head injury and damages the hypothalamus. Which vital sign will the nurse monitor most closely?
A patient has a head injury and damages the hypothalamus. Which vital sign will the nurse monitor most closely?
A patient presents with heatstroke. The nurse uses cool packs, cooling blanket, and a fan. Which technique is the nurse using when the fan produces heat loss?
A patient presents with heatstroke. The nurse uses cool packs, cooling blanket, and a fan. Which technique is the nurse using when the fan produces heat loss?
The patient has a temperature of 105.2F. The nurse is attempting to lower temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. Which technique is the nurse using to lower the patient’s temperature?
The patient has a temperature of 105.2F. The nurse is attempting to lower temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. Which technique is the nurse using to lower the patient’s temperature?
A nurse is focusing on temperature regulation of newborns and infants. Which action will the nurse take?
A nurse is focusing on temperature regulation of newborns and infants. Which action will the nurse take?
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The nurse is working the night shift on a surgical unit and is making 4:00 AM rounds. The nurse notices that the patient’s temperature is 96.8F (36C), whereas at 4:00 PM the
preceding day, it was 98.6F (37C). What should the nurse do?
The nurse is working the night shift on a surgical unit and is making 4:00 AM rounds. The nurse notices that the patient’s temperature is 96.8F (36C), whereas at 4:00 PM the preceding day, it was 98.6F (37C). What should the nurse do?
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The nurse is caring for a patient who has a temperature reading of 100.4F (38C). The patient’s last two temperature readings were 98.6F (37C) and 96.8F (36C). Which action
will the nurse take?
The nurse is caring for a patient who has a temperature reading of 100.4F (38C). The patient’s last two temperature readings were 98.6F (37C) and 96.8F (36C). Which action will the nurse take?
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A patient is experiencing pyrexia. Which piece of equipment will the nurse obtain to monitor this condition?
A patient is experiencing pyrexia. Which piece of equipment will the nurse obtain to monitor this condition?
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The nurse is caring for a patient who has an elevated temperature. Which principle will the nurse consider when planning care for this patient?
The nurse is caring for a patient who has an elevated temperature. Which principle will the nurse consider when planning care for this patient?
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The patient with heart failure is restless with a temperature of 102.2F (39C). Which action will the nurse take?
The patient with heart failure is restless with a temperature of 102.2F (39C). Which action will the nurse take?
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The patient requires temperatures to be taken every 2 hours. Which task will be the responsibility of an RN?
The patient requires temperatures to be taken every 2 hours. Which task will be the responsibility of an RN?
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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?
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?
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The patient is being admitted to the emergency department following a motor vehicle accident. The patient’s jaw is broken with several broken teeth. The patient is ashen, has cool skin, and is diaphoretic. Which route will the nurse use to obtain an accurate temperature reading?
The patient is being admitted to the emergency department following a motor vehicle accident. The patient’s jaw is broken with several broken teeth. The patient is ashen, has cool skin, and is diaphoretic. Which route will the nurse use to obtain an accurate temperature reading?
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The nurse is caring for an infant and is obtaining the patient’s vital signs. Which artery will the nurse use to best obtain the infant’s pulse?
The nurse is caring for an infant and is obtaining the patient’s vital signs. Which artery will the nurse use to best obtain the infant’s pulse?
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The patient is found to be unresponsive and not breathing. Which pulse site will the nurse use?
The patient is found to be unresponsive and not breathing. Which pulse site will the nurse use?
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The nurse needs to obtain a radial pulse from a patient. What must the nurse do to obtain a correct measurement?
The nurse needs to obtain a radial pulse from a patient. What must the nurse do to obtain a correct measurement?
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The nurse is assessing the patient’s respirations. Which action by the nurse is most appropriate?
The nurse is assessing the patient’s respirations. Which action by the nurse is most appropriate?
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The patient’s blood pressure is 140/60. Which value will the nurse record for the pulse pressure?
The patient’s blood pressure is 140/60. Which value will the nurse record for the pulse pressure?
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The nurse reviews the laboratory results for a patient and determines the viscosity of the blood is thick. Which laboratory result did the nurse check?
The nurse reviews the laboratory results for a patient and determines the viscosity of the blood is thick. Which laboratory result did the nurse check?
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The patient is being admitted to the emergency department with reports of shortness of breath. The patient has had chronic lung disease for many years but still smokes. What will the nurse do?
The patient is being admitted to the emergency department with reports of shortness of breath. The patient has had chronic lung disease for many years but still smokes. What will the nurse do?
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A nurse is reviewing capnography results for adult patients. Which value will cause the nurse to follow up?
A nurse is reviewing capnography results for adult patients. Which value will cause the nurse to follow up?
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The nurse is caring for a patient who has a pulse rate of 48. His blood pressure is within normal limits. Which finding will help the nurse determine the cause of the patient’s low heart rate?
The nurse is caring for a patient who has a pulse rate of 48. His blood pressure is within normal limits. Which finding will help the nurse determine the cause of the patient’s low heart rate?
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The patient was found unresponsive in an apartment and is being brought to the emergency department. The patient has arm, hand, and leg edema, temperature is 95.6F, and hands are cold secondary to a history of peripheral vascular disease. It is reported that the patient has a latex allergy. What should the nurse do to quickly measure the patient’s oxygen saturation?
The patient was found unresponsive in an apartment and is being brought to the emergency department. The patient has arm, hand, and leg edema, temperature is 95.6F, and hands are cold secondary to a history of peripheral vascular disease. It is reported that the patient has a latex allergy. What should the nurse do to quickly measure the patient’s oxygen saturation?
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The patient is admitted with shortness of breath and chest discomfort. Which laboratory value could account for the patient’s symptoms?
The patient is admitted with shortness of breath and chest discomfort. Which laboratory value could account for the patient’s symptoms?
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A nurse reviews blood pressures of several patients. Which finding will the nurse report as prehypertension?
A nurse reviews blood pressures of several patients. Which finding will the nurse report as prehypertension?
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The nurse is providing a blood pressure clinic for the community. Which group will the nurse most likely address?
The nurse is providing a blood pressure clinic for the community. Which group will the nurse most likely address?
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A nurse is caring for a patient who smokes and drinks caffeine. Which point is important for
the nurse to understand before assessing the patient’s blood pressure (BP)?
A nurse is caring for a patient who smokes and drinks caffeine. Which point is important for the nurse to understand before assessing the patient’s blood pressure (BP)?
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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?
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?
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The nurse is caring for an older-adult patient and notes that the temperature is 96.8F (36C). How will the nurse interpret this finding?
The nurse is caring for an older-adult patient and notes that the temperature is 96.8F (36C). How will the nurse interpret this finding?
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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?
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?
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The nurse is caring for a small child and needs to obtain vital signs. Which site choice from the nursing assistive personnel (NAP) will cause the nurse to have confidence in the NAP?
The nurse is caring for a small child and needs to obtain vital signs. Which site choice from the nursing assistive personnel (NAP) will cause the nurse to have confidence in the NAP?
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The nurse is caring for a newborn infant in the hospital nursery and notices that the infant is breathing rapidly but is pink, warm, and dry. Which normal respiratory rate will the nurse consider when planning care for this newborn?
The nurse is caring for a newborn infant in the hospital nursery and notices that the infant is breathing rapidly but is pink, warm, and dry. Which normal respiratory rate will the nurse consider when planning care for this newborn?
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The nurse is preparing to obtain an oxygen saturation reading on a toddler. Which action will
the nurse take?
The nurse is preparing to obtain an oxygen saturation reading on a toddler. Which action will the nurse take?
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The nurse is preparing to assess the blood pressure of a 3-year-old. How should the nurse proceed?
The nurse is preparing to assess the blood pressure of a 3-year-old. How should the nurse proceed?
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A nurse is caring for a group of patients. Which patient will the nurse see first?
A nurse is caring for a group of patients. Which patient will the nurse see first?
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The nurse is caring for a patient who is being discharged from the hospital after being treated for hypertension. The patient is instructed to take blood pressure 3 times a day and to keep a record of the readings. The nurse recommends that the patient purchase a portable electronic blood pressure device. Which other information will the nurse share with the patient?
The nurse is caring for a patient who is being discharged from the hospital after being treated for hypertension. The patient is instructed to take blood pressure 3 times a day and to keep a record of the readings. The nurse recommends that the patient purchase a portable electronic blood pressure device. Which other information will the nurse share with the patient?
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The nurse is caring for a patient who reports feeling light-headed and ―woozy.‖ The nurse checks the patient’s pulse and finds that it is irregular. The patient’s blood pressure is 100/72. It was 113/80 an hour earlier. What should the nurse do?
The nurse is caring for a patient who reports feeling light-headed and ―woozy.‖ The nurse checks the patient’s pulse and finds that it is irregular. The patient’s blood pressure is 100/72. It was 113/80 an hour earlier. What should the nurse do?
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A nurse is caring for a group of patients. Which patient will the nurse see first?
A nurse is caring for a group of patients. Which patient will the nurse see first?
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The health care provider prescription reads ―Metoprolol 50 mg PO daily. Do not give if blood pressure is less than 100 mm Hg systolic.‖ The patient’s blood pressure is 92/66. The nurse does not give the medication. Which action should the nurse take?
The health care provider prescription reads ―Metoprolol 50 mg PO daily. Do not give if blood pressure is less than 100 mm Hg systolic.‖ The patient’s blood pressure is 92/66. The nurse does not give the medication. Which action should the nurse take?
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After taking the patient’s temperature, the nurse documents the value and the route used to obtain the reading. What is the reason for the nurse’s action?
After taking the patient’s temperature, the nurse documents the value and the route used to obtain the reading. What is the reason for the nurse’s action?
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When taking an adult blood pressure, the onset of the sound the nurse hears is at 138, the muffled sound the nurse hears is at 70, and the disappearance of the sound the nurse hears is at 62. How should the nurse record this finding?
When taking an adult blood pressure, the onset of the sound the nurse hears is at 138, the muffled sound the nurse hears is at 70, and the disappearance of the sound the nurse hears is at 62. How should the nurse record this finding?
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The nursing assistive personnel (NAP) is taking vital signs and reports that a patient’s blood pressure is abnormally low. What should the nurse do next?
The nursing assistive personnel (NAP) is taking vital signs and reports that a patient’s blood pressure is abnormally low. What should the nurse do next?
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Study Notes
Vital Signs Monitoring
- Closely monitor temperature for patients with hypothalamus damage due to its role in regulating body temperature.
- For a patient presenting heatstroke, cooling techniques (cool packs, blankets, fan) contribute to heat loss through convection, where air movement aids in body heat dissipation.
Temperature Regulation Techniques
- Tepid sponge baths and cool compresses are used to manage hyperthermia, effectively lowering body temperature through conduction and evaporation.
- Infants and newborns require careful temperature monitoring; maintaining normothermia is critical due to their limited ability to regulate body heat.
Temperature Assessment Protocols
- A notable drop in temperature from previous readings (e.g., 98.6F to 96.8F) requires further investigation to determine potential causes, such as infection or environmental factors.
- In cases of fever (100.4F), reassessing the patient's condition and checking for associated symptoms is essential.
Equipment and Blood Pressure Management
- A thermometer is necessary for monitoring pyrexia, while providing comfort and identifying trends in temperature is crucial for patient care.
- For a heart failure patient with elevated temperature revealing restlessness, assessing hydration status and managing fever may be prioritized.
RN Responsibilities
- Routine temperature checks every 2 hours can be executed by Registered Nurses (RNs); leading assessment for confusional patients should involve the least invasive and safest route for temperature measurement.
- Accurate temperature readings for patients with broken jaws or facial trauma may involve using tympanic or temporal artery thermometers for precision.
Respiratory and Pulse Assessment
- The pulse in infants is best obtained from the brachial artery for accuracy, while unresponsive patients or those with severe peripheral vascular disease necessitate using the carotid pulse for critical care situations.
- To acquire a radial pulse effectively, proper positioning and ensuring the patient's calmness are necessary to prevent incorrect readings.
Blood Pressure Evaluation
- The pulse pressure is calculated as the difference between systolic and diastolic readings. For example, a reading of 140/60 results in a pulse pressure of 80.
- Normal interpretations of blood pressure readings include identifying prehypertension and recognizing hypertension, particularly in populations at risk (e.g., frequent smokers).
Pediatric and Geriatric Considerations
- In infants, a pulse rate of 145 beats/minute is considered normal; understanding pediatric norms is essential for accurate health assessments.
- Older adults may have lower baseline temperatures; a reading of 96.8°F could be normal and not necessarily a cause for concern.
Oxygen Saturation and Lab Values
- Rapid respiratory rates in newborns should be assessed against expected norms; interventions must be guided by stable vital signs.
- Capnography results need to follow up on abnormal values; low heart rates in patients (like 48 bpm) require investigation into potential causes including medication effects or underlying conditions.
Patient Education and Discharge Instructions
- Advise patients with hypertension about the importance of regular monitoring and keeping an accurate record of blood pressure readings using reliable devices.
- Irregular pulse rates with dizziness warrant immediate re-evaluation of patient status and potential intervention before further medication administration.
Documentation and Responsibilities
- Document not only the temperature value but also the route of measurement for clear clinical records.
- When abnormal vital signs are reported by nursing assistive personnel (NAP), the nurse should verify the readings promptly to ensure patient safety.
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Description
This quiz focuses on the nursing considerations when caring for patients with head injuries, particularly those affecting the hypothalamus. Understanding the vital signs to monitor in these cases is crucial for effective patient management. Test your knowledge of nursing assessments and interventions in neurological trauma.
