The nurse is assessing a toddler when the child's mother states ...

[sabina]

The nurse is assessing a toddler when the child's mother states that the child has had a fever for the past two days.
 
  When the nurse asks the mother what the temperature has been, the mother replies that she hasn't actually taken it but the child's skin has felt very warm. Which response by the nurse is appropriate in this situation?
  1. When our skin feels warm, it means our blood vessels are constricted.
  2. The only reliable indicator of body temperature is by feeling the forehead.
  3. Our skin temperature changes when our surroundings change temperature.
  4. The temperature of the skin is not related to what is happening inside our bodies.

Question 2

The nurse educator is observing the student nurse take a blood pressure on an older adult client. When is it appropriate for the nurse educator to intervene during this assessment?
 
  Select all that apply.
  1. The student nurse ushers the client into the exam room and immediately assesses the client's blood pressure.
  2. The student nurse places the blood pressure cuff on the client's arm over a lightweight, long-sleeved sweater.
  3. The student nurse immediately reinflates the cuff after identifying the palpatory systolic blood pressure.
  4. The student nurse has the client sit in a chair and supports the client's arm on a table at the level of the heart.
  5. The student nurse places the blood pressure cuff on the thigh of a client with a bilateral mastectomy and takes the blood pressure using the popliteal artery.

[Alyson.hiatt@yahoo.com]

Answer to Question 1

Correct Answer: 3

The surface temperature of the body is constantly changing in response to environmental influences, and as a result, is not a reliable indicator of actual health status. To obtain accurate temperature, the core temperature, or the temperature of the deep tissues of the body, needs to be assessed. Fever causes vasodilation, not vasoconstriction. When fever is present, the skin all over the body may feel warm, not just the forehead, thus the only reliable indicator of body temperature is measuring the core temperature with a thermometer. The temperature of the skin is related to what is happening inside the body. Fever is a sign of the disruption of homeostasis in the body. This may be due to a bacterial or viral infection. Fever causes vasodilation, which can make the skin feel warm to the touch.

Answer to Question 2

Correct Answer: 1, 2, 3
The client should sit quietly for at least 5 minutes before the blood pressure is taken. Immediately assessing the blood pressure after a client walks from the waiting room to exam room may not yield an accurate reading. The client's blood pressure should be assessed on a bare arm. If the client is wearing a long-sleeved garment and it can be pushed up without constricting the arm, this is acceptable; otherwise the arm should be removed from the sleeve. Once the cuff is inflated and the nurse identifies the palpatory systolic blood pressure, the nurse should wait at least 15-30 seconds before inflating the cuff again. In order to obtain an accurate blood pressure, the client should be seated with the arm slightly flexed, supported at the level of the heart with palm facing up. Clients who have suffered trauma to the upper extremities, have shunts in the upper extremities, or have had mastectomies should not have their blood pressures assessed on the affected sides. The nurse can place the blood pressure cuff on the thigh and assess the blood pressure using the popliteal artery.