A mother brings her 3-year-old daughter to the emergency department because the child has been vomiting and having diarrhea for the past 36 hours. When assessing this child'stemperature, which method would be least appropriate?
Tympanic
Oral
Axillary
Rectal
The Correct Answer is D
A. TympaniC. Tympanic temperature measurement using an ear thermometer is a convenient and accurate method for assessing temperature in children, including toddlers.
B. Oral: Oral temperature measurement using a digital thermometer placed under the tongue is a commonly used method for children who can cooperate with the procedure and keep the
thermometer in their mouth.
C. Axillary: Axillary temperature measurement using a thermometer placed in the armpit is a non-invasive method suitable for children who cannot cooperate with oral or tympanic
measurements or when rectal measurement is contraindicated.
D. Rectal: Rectal temperature measurement is generally considered the most accurate method for assessing temperature in infants and young children, especially when accuracy is critical.
However, it may be less appropriate in the emergency department setting due to its invasive nature and potential discomfort for the child, especially in cases of diarrhea or vomiting where rectal temperature measurement may be difficult or impractical.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Eruption of the last four molars: This characteristic typically occurs during adolescence but may vary individually. However, it is not universal among all teenagers and does not apply to both genders equally.
B. Increased shoulder, chest, and hip widths: During adolescence, both boys and girls experience growth spurts, leading to increased shoulder, chest, and hip widths as part of their overall physical development.
C. Decreased respiratory rates of 15 to 20 breaths per minutE. Respiratory rates in teenagers generally remain within the normal adult range, typically between 12 and 20 breaths per minute. There is no consistent decrease in respiratory rates during adolescence.
D. Fully functioning sweat and sebaceous glands: Sweat and sebaceous glands are typically fully developed and functional by adolescence. This characteristic is not specific to teenagers but applies to individuals of all ages once these glands have matured.
Correct Answer is A
Explanation
A. "I will give him a pacifier during feeding time.": Giving a pacifier during feeding time may interfere with the infant's ability to coordinate sucking, swallowing, and breathing, especially if
they are receiving nutrition through a nasogastric tube. This response indicates a need for further teaching because pacifiers during feeding time could potentially disrupt the infant's feeding
pattern and may not be appropriate in this situation.
B. "We need to make sure he doesn't lose the desire to eat by mouth.": This response
demonstrates an understanding of the importance of maintaining the infant's oral feeding skills and indicates appropriate knowledge about promoting oral feeding while using a nasogastric
tube.
C. "We need to keep feeding time very quiet.": Keeping feeding time quiet can help reduce distractions and promote a calm environment, which may enhance feeding tolerance for the infant. This response reflects an understanding of strategies to facilitate feeding.
D. "Sucking produces saliva, which aids in digestion.": This response demonstrates knowledge about the benefits of sucking and saliva production during feeding, indicating an understanding of the infant's physiological needs during feeding.
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