The nurse is obtaining the initial vital signs on a client in the ...

[imanialler]

The nurse is obtaining the initial vital signs on a client in the emergency department (ED) with seizure activity of unknown etiology. Which method is most appropriate for the nurse to use when assessing the client's temperature?
 
  1. Axillary.
  2. Oral.
  3. Rectal.
  4. Tympanic.

Question 2

The nurse is preparing to assess a client's mental status within the general survey. Which data should the nurse use to assess this status?
 
  1. Noting of the number of times the client looks to significant other while answering interview questions.
  2. Asking the client to describe elements of his health history.
  3. Studying the client's clothing selections.
  4. Noticing the client's ability to make eye contact during the examination.

[pocatato]

Answer to Question 1

Correct Answer: 3

A rectal temperature should be taken if the client is comatose, confused, having seizures, or unable to close the mouth. Although axillary is the safest, it is also the least accurate. Both oral and tympanic require the client's cooperation in order to maintain safety, which is not possible during seizure activity.

Answer to Question 2

Correct Answer: 2

The general survey is composed of four major categories of observation: physical appearance, mental status, mobility, and client behavior. Asking the client to describe elements of his health history would help assess mental status. Observing the client walking into the examination room would help assess mobility. Studying the client's clothing selections would help assess physical appearance. Noticing the client's ability to make eye contact would help assess client behavior.

[imanialler]

Gracias!

[bblaney]

TYSM