Chapters 8-12

The neonate's temperature normally ranges from 96° to 99.5°F (35.5° to 37.5°C). Temperature regulation is labile (unstable) during infancy because of immature physiologic mechanisms. Axillary measurement is considered the least accurate method and is used less frequently since the advent of the tympanic membrane thermometer. Tympanic thermometer readings are suitable for patients of all ages, except infants.

A nurse assesses a neonate's temperature by using a temporal artery scanner. What intervention should the nurse implement if the neonate's temperature is 96°F (35.5°C)?

The neonate's temperature normally ranges from 96° to 99.5°F (35.5° to 37.5°C). Temperature regulation is labile (unstable) during infancy because of immature physiologic mechanisms. Axillary measurement is considered the least accurate method and is used less frequently since the advent of the tympanic membrane thermometer. Tympanic thermometer readings are suitable for patients of all ages, except infants.

A nurse assesses a neonate's temperature by using a temporal artery scanner. What intervention should the nurse implement if the neonate's temperature is 99.5°F (37.5°C)?

A bounding pulse feels full and springlike even under moderate pressure. A thready pulse is difficult to feel and is not palpable when only slight pressure is applied. A weak pulse is somewhat stronger than a thready pulse but not palpable when light pressure is applied. A normal pulse is easily felt but not palpable when moderate pressure is applied.

A nurse assesses a patient's dorsalis pedis pulse. The pulse feels full and springlike even under moderate pressure. How should the nurse document this finding?

A thready pulse is difficult to feel and is not palpable when only slight pressure is applied. A weak pulse is somewhat stronger than a thready pulse but not palpable when light pressure is applied. A normal pulse is easily felt but not palpable when moderate pressure is applied. A bounding pulse feels full and springlike even under moderate pressure.

A nurse assesses a patient's dorsalis pedis pulse. The pulse is difficult to feel and not palpable when only slight pressure is applied. How should the nurse document this finding?

The skin of older adults is more fragile and susceptible to injury. When moving or transferring older adults, it is essential to avoid pulling them across bed linens because this may cause shearing or tearing of the skin. The nurse should explain each step in simple language and avoid jerky, sudden movements.

A nurse instructs a unlicensed assistive personnel about moving older adult patients in bed. When should the nurse intervene when observing the unlicensed assistive personnel perform a return demonstration?

Greeting the patient by name is one of the most important aspects of admission.

A nurse is admitting a patient to an acute care facility. During the admission procedure, what nursing intervention would best help reduce patient anxiety?

Some Haitian Americans associate wheelchairs with being sick. Therefore, on discharge, the patient who is allowed to walk out of the hospital will be more likely to feel that care has been effective. A poor patient with a Haitian background and a wealthy patient with a Haitian background, although from the same country, may find the same room assignment together in the hospital very distasteful.

A nurse is caring for a Haitian American patient. How might the nurse demonstrate cultural sensitivity?

The difference between radial and apical pulses is called a pulse deficit.

A patient is suspected of having a cardiac arrhythmia. The nurse is concerned with the findings of an apical rate of 88 and a radial rate of 80. What is the term for the difference between these two rates?

Many Haitians believe that leaves have a special significance in healing. Leaves may be found in the clothes and on various parts of the body. Leaves are thought to have mystical power related to regaining or keeping health.

How can the nurse demonstrate cultural sensitivity to a Haitian American patient?

The nurse may want to administer medication before an activity that may be painful.

How should the nurse assist the patient with moving when pain is anticipated?

Using the tympanic thermometer for a child, the nurse will tug the ear pinna down and back.

How should the nurse position the ear pinna when using the tympanic thermometer on a child?

To ensure the best reception of sound, place earpieces pointing toward the face.

How should the nurse position the earpieces on a stethoscope to ensure optimum reception?

The interagency transfer moves a patient from one health care agency to another.

If a patient has an order for an interagency transfer, where does the nurse explain that the patient will be moved?

The suggested maximum weight considered safe to lift by a single person is 50 lb.

The 125-lb nurse is preparing to lift a heavy object. What is the maximum amount of weight considered safe for the nurse to lift?

Death can occur if the temperature falls below 93.2° F (34°C).

The emergency department nurse quickly assesses the temperature of an unconscious patient who has been outside all night in below-freezing temperatures. What temperature is the nurse aware of that can lead to death?

The patient who is using ancillary muscles to breathe is exhibiting dyspnea.

The nurse assesses respirations of a patient demonstrating pursed-lip breathing, flared nostrils, and retractions. How will the nurse describe these respirations?

Proper body mechanics provide for even distribution of workload.

The nurse instructs a unlicensed assistive personnel to use large muscle groups when lifting. What is the rationale for this instruction?

The purpose of mobility is completing ADLs and maintaining physiologic activities.

The nurse is educating a patient on ways to regain the ability to perform ADLs and maintain normal physiologic activities. What will the nurse relay as a requirement?

The joints are moved to the point of resistance or pain.

The nurse is performing passive range of motion (ROM) for the patient. How will the nurse move the joint through ROM?

Each movement should be repeated five times.

The nurse is performing passive range-of-motion exercises on a patient following a traumatic injury. What is the number of times the nurse should move each joint when performing passive range-of-motion (ROM) exercises?

The older adult may demonstrate depression as a result of separation anxiety entering the hospital.

The nurse must be sensitive to an older adult patient experiencing separation anxiety when admitted to the hospital. When a child experiences separation anxiety, they will usually cry. What will an older adult often demonstrate when experiencing separation anxiety?

Bradycardia can result from unrelieved severe pain.

The patient's pulse is below 60 beats/min. The nurse is aware that the patient is not receiving digoxin. What does the nurse suspect is causing the bradycardia?

Valuables should be locked in the hospital safe.

Upon admission, the nurse notes that a patient without family members present has a billfold filled with cash. Where can the nurse suggest the money be placed?

Lung sounds are auscultated by using the diaphragm of the stethoscope.

What does the nurse use the diaphragm of the stethoscope to best assess?

As a general rule, the nurse should use a transfer belt.

What implementation might the nurse use to improve safety during a transfer?

The amount of exercise required to prevent physical disuse syndrome is 2 hours in 24 hours.

What is considered to be the minimum number of hours of daily activity necessary to prevent the negative consequences of immobility?

The most common back injury is strain of the lumbar muscle group.

What is the site of the most common strain injury acquired by the nurse when working?

A remittent fever does not return to normal until the patient becomes well.

What is the term for a fever that rises and falls but does not return to normal until the patient is well?

Internal respiration is the exchange of gas at the alveolar level.

What is the term for the exchange of carbon dioxide and oxygen that takes place at the alveolar level?

Body temperature is regulated by the hypothalamus.

What part of the body maintains a balance between heat production and heat loss, regulating body temperature?

Studies of workers' compensation claims show that nursing personnel have the highest claim rates of any occupation or industry.

What profession has the highest workers' compensation claim rates of any occupation or industry?

The nurse's back can be well protected when he or she bends knees and hips.

What should the nurse do to protect his or her back when lifting or moving a patient?

The base of support should be broadened in the direction of movement.

What should the nurse do to reduce the effort of moving a heavy object?

The carotid site is the best for finding a pulse quickly.

What site should be selected if a peripheral pulse needs to be assessed quickly?

The core body temperature remains relatively constant.

What type of body temperature remains relatively constant?

Fear of the unknown may be the most common reaction to hospitalization.

When admitting a patient to the hospital, the nurse observes that the patient is distracted and tense. What does this behavior suggest as a common reaction to hospitalization?

Discharge planning begins shortly after admission.

When should discharge planning begin?

Often a patient will require services of various disciplines within the hospital. Social services can assist with meeting medical financial obligations.

Where can a nurse refer the family of a patient to find a source of financial aid to meet medical expenses?

The nurse should carry objects close to the midline of the body.

Where should the nurse place the load when carrying heavy objects?

It is essential that the patient be fully aware of the discharge instructions before being discharged.

Before the actual discharge occurs, what must the nurse ensure?