Exam 1 Study

The father of a toddler tells the nurse that his child had a fever the previous night. During the assessment, which statement by the father indicates further discussion is necessary regarding temperature measurement?

• "I used one of those thermometers that goes in the ear, but I don't think it was accurate."

• "We have an electronic oral thermometer. It seemed to match our child's symptoms of fever better."

• "My mother said she always used a glass thermometer when I was a kid and it was very accurate. Maybe that would be better."

• "I know rectal temperature is pretty accurate but I didn't see that it was necessary to cause the discomfort of that route."

The nurse has just measured an adult client’s oral temperature and obtained a result of 102.4 F. The client states, "I just finished my coffee right before you came in. Can I have another cup?" Which of the following response by the nurse is most appropriate?

• Before you drink another hot beverage, drink some cool water so I can obtain an accurate oral temperature

• I will bring you another cup when I return in 30 minutes to reassess your temperature. Please do not drink any other beverages until I return

• I will be right back with your coffee and a different thermometer. I'm not sure this one measured your temperature correctly

• You need to remain NPO until I notify your primary health care provider about your increased temperature

A nurse assesses an oral temperature for an adult patient and records that the patient is “afebrile.” What would be the nurse’s best response to this finding?

• Check the patient record for prescribed antipyretic medication.

• Report the finding to the primary care provider.

• Take the patient temperature using a different method.

• No action is necessary; this is a normal reading.

Upon assessment of a patient, the nurse determines that a patient is at risk of losing body heat through the process of convection. What would be the nurse’s best response?

• Turn off the overhead fan in the patient’s room.

• Remove the patient’s ice pack.

• Reduce the temperature in the room

• Increase the temperature in the room.

If a patient’s temperature was 97.7 at 8:00 AM. It is now 98.9 at 9:00 AM. What would you do as the nurse?***

• Administer Tylenol

• Sponge bath

• Alert the nurse.

• Nothing

The nurse has just administered ibuprofen (Motrin) to a child with a temperature of 38.8° C (102° F). The nurse should also take which action?***

• Withhold oral fluids for 8 hours.

• Sponge the child with cold water.

• Plan to administer salicylate (aspirin) in 4 hours.

• Remove excess clothing and blankets from the child.

The nurse is caring for a child after surgical removal of a brain tumor. The nurse should assess the child for which sign that would indicate that brainstem involvement occurred during the surgical procedure?***

• Inability to swallow

• Elevated temperature

• Altered hearing ability

• Orthostatic hypotension

A nurse is teaching a novice nurse how to provide care for patients in a culturally diverse community health clinic. Although all these actions are recommended, which one is MOST basic to providing culturally competent care?

• Learning the predominant language of the community

• Obtaining significant information about the community

• Treating each patient at the clinic as an individual

• Recognizing the importance of the patient’s family

The nurse practitioner sees patients in a community clinic that is located in a predominately White neighborhood. After performing assessments on the majority of the patients visiting the clinic, the nurse notes that many of the minority groups living within the neighborhood have lost the cultural characteristics that made them different. What is the term for this process?

• Cultural assimilation

• Cultural imposition

• Culture shock

• Ethnocentrism

What does R.I.C.E stand for?

• Rise, ice, compress, elevate

• Rest, ice, complain, elevate

• Rest, ice, compress, elevate

• Rise, ice, compress, early