A nurse is assessing a client who has an oral temperature of 39 C (102.27 F). Which of the following findings should the nurse expect?

Decreased peripheral pulses

Heart rate 108/min

Respiratory rate 10 breathes/min

Dilated pupils

Answer and Explanation

The Correct Answer is B

A) Decreased peripheral pulses:
Increased body temperature typically causes vasodilation rather than vasoconstriction, leading to improved blood flow rather than decreased. As a result, peripheral pulses are more likely to be normal or even increased in response to fever. Decreased peripheral pulses would be more indicative of conditions like shock or hypoperfusion, not fever.

B) Heart rate 108/min:
Fever causes an increase in metabolic demand, which often results in a compensatory increase in heart rate (tachycardia). This phenomenon, known as "fever tachycardia," occurs as the body attempts to circulate blood more rapidly to meet the increased oxygen and nutrient demands caused by elevated body temperature. A heart rate of 108 beats per minute is a normal response to fever, particularly when the temperature reaches 39°C (102.27°F).
C) Respiratory rate 10 breaths/min:
A respiratory rate of 10 breaths per minute is considered bradypnea (abnormally slow breathing), which is typically not associated with fever. Fever usually leads to an increase in respiratory rate (tachypnea) as the body attempts to cool itself through increased evaporation of sweat and breathing. A respiratory rate of 10 breaths/min is more likely to be seen in conditions like drug overdose, head injury, or respiratory depression, rather than fever.
D) Dilated pupils:
Dilated pupils (mydriasis) are typically associated with sympathetic nervous system activation, which can be caused by certain drugs, trauma, or neurological conditions. Fever, however, generally causes only mild changes in pupil size and is more likely to lead to constricted pupils (miosis) in response to certain stress hormones. Dilated pupils are not a typical finding with fever.

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Correct Answer is D

Explanation

A) A client who has heart failure and peripheral edema:
While heart failure and peripheral edema are significant conditions that require medical attention, they are chronic issues that, in most cases, are not immediately life-threatening in an emergency department setting unless there is acute decompensated heart failure or signs of severe fluid overload or respiratory distress.

B) A client who reports urinary burning and a temperature of 29.2° C (102.5°F):
This client is febrile, which suggests an infection, possibly a urinary tract infection (UTI). Although fever and urinary burning are concerning, infection-related fevers generally don't pose an immediate life threat unless there is sepsis or severe systemic involvement. A temperature of 102.5°F is significant, but the client's condition is not as urgent as other life-threatening emergencies like an arrhythmia or severe cardiovascular instability.

C) A client who has cirrhosis of the liver and bruising on their arms:
Bruising in a client with cirrhosis of the liver could indicate bleeding tendencies, which is an important concern. However, unless there is active bleeding or signs of severe liver failure (e.g., confusion, ascites, jaundice), this is not an immediate, life-threatening situation.

D) A client who has a new onset of atrial fibrillation and a heart rate of 152/min:
A new onset of atrial fibrillation (AF) with a heart rate of 152/min is an immediate priority. This is a life-threatening arrhythmia that can lead to decreased cardiac output, risk of stroke, and hemodynamic instability. A heart rate of 152 beats per minute is dangerously high, which could lead to tachycardia-induced cardiomyopathy or cardiogenic shock. Immediate intervention is needed to manage the arrhythmia and prevent further complications.

A. I will wear earphones during this test." B. "A small probe is placed inside my ear." C. A tuning fork is placed on my head" D. "Small electrodes are placed on my scalp

Correct Answer is C

Explanation

A) "I will wear earphones during this test":
This statement is incorrect. The Rinne test is a hearing test used to compare air conduction to bone conduction of sound. It is performed by placing a vibrating tuning fork near the ear canal (for air conduction) and then on the mastoid bone behind the ear (for bone conduction). Earphones are not used in this test.

B) "A small probe is placed inside my ear":
This statement is incorrect. A probe is typically used for other types of hearing tests, such as tympanometry or an auditory brainstem response (ABR) test, not the Rinne test. The Rinne test involves using a tuning fork, not a probe, and the tuning fork is placed near the ear canal (for air conduction) and on the mastoid bone (for bone conduction).

C) "A tuning fork is placed on my head":
This statement is correct. In the Rinne test, the tuning fork is initially struck to produce sound and then placed on the mastoid bone (behind the ear) to test bone conduction. Afterward, the vibrating tuning fork is moved to the front of the ear canal to test air conduction. The purpose of the test is to compare these two types of conduction. If air conduction is better than bone conduction, this suggests normal hearing, while equal or better bone conduction can indicate conductive hearing loss.

D) "Small electrodes are placed on my scalp":
This statement is incorrect. Electrodes on the scalp are typically used in an electroencephalogram (EEG) or other neurodiagnostic tests, not the Rinne test. The Rinne test focuses on hearing and does not require the use of electrodes. It uses a tuning fork to assess how well sound travels through air and bone.

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A nurse is assessing a client who has an oral temperature of 39 C (102.27 F). Which of the following findings should the nurse expect?

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