Author Question: When assessing a client's vital signs, a nursing student has explained each of her next actions ... (Read 31 times)

mikaylakyoung · **on:** Jul 23, 2018

When assessing a client's vital signs, a nursing student has explained each of her next actions prior to assessing the client's temperature, pulse, and blood pressure.

However, the nurse has not announced her intention to assess the client's respiratory rate prior to measuring it. Which of the following is a plausible rationale for the nurse's decision?

A) Respirations have both autonomic and voluntary control.
B) The nurse likely assessed the client's respiratory rate simultaneous to heart rate.
C) Temperature, pulse, and blood pressure are more volatile than respiratory rate.
D) Tachypnea is an expected finding among hospitalized individuals.

Question 2

An male client 86 years of age with a diagnosis of vascular dementia and cardiomyopathy is exhibiting signs and symptoms of pneumonia.

The nurse has attempted to assess his temperature using an oral thermometer, but the client is unable to follow directions to close his mouth and secure the thermometer sublingually. Additionally, he repeatedly withdraws his head when the nurse attempts to use a tympanic thermometer. How should the nurse proceed with this assessment?

A) Assess the client's temperature by axilla.
B) Assess the client's skin tone and the presence or absence of sweating to determine whether the client is febrile.
C) Use a disposable mercury thermometer to take the client's temperature.
D) Take the client's temperature rectally.

fatboyy09 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Ans: A
Because respiratory rate is under both autonomic and voluntary control, making the client conscious of his or her respiratory rate prior to assessment has the potential to affect that accuracy of the assessment. It is not possible to simultaneously assess pulse and respirations. Temperature, pulse, and blood pressure are not necessarily more volatile than respiratory rate. Tachypnea is not an expected finding.

Answer to Question 2

Ans: A
The axillary site is an accurate and acceptable alternative when other sites are impractical or contraindicated. Rectal temperatures are contraindicated in cardiac clients; mercury thermometers are not commonly used. It is unacceptable for the nurse to rely solely on subjective assessments to determine whether the client is febrile.