A nurse is assisting with the care of a client.

Exhibits

The nurse is reinforcing teaching for the client and their family about potential adverse effects of the client's prescribed medications.

For each potential adverse effect, click to specify if the effect is. consistent with agranulocytosis, neuroleptic malignant syndrome, or. serotonin syndrome.

Each finding may support more than 1 disease process.

The correct answer is: c. The AP pulls the pinna up and back.

Choice A reason: The AP inserting the probe with a straight, forward motion is not the correct technique for tympanic temperature measurement. The ear canal does not run straight forward into the head; instead, it curves slightly. Inserting the probe straight forward could potentially damage the ear canal or eardrum and would not provide an accurate temperature reading.

Choice B reason: Pointing the probe posteriorly is also incorrect. The tympanic membrane is located at the end of the ear canal, and the probe should be directed towards it. However, the probe should be angled slightly downward and toward the jawline, not straight back, to align with the ear canal and ensure an accurate reading.

Choice C reason: Pulling the pinna up and back is the correct method for adults and children over one year old. This action straightens the ear canal, allowing the thermometer’s sensor to get a clear path to the tympanic membrane, which is necessary for an accurate temperature reading. For infants, the correct method is to pull the earlobe straight back.

Choice D reason: The AP positioning the client facing her does not directly relate to the technique of measuring tympanic temperature. While it may be necessary for the AP to see the client’s ear, it is not an indication of understanding the correct procedure for tympanic temperature measurement.

Answer is: A, B, and C.Respiratory rate, oxygen saturation level, and heart rate are the three findings that require immediate follow-up. These findings indicate that the client is experiencing respiratory distress and possible complications of pneumonia, such as sepsis and cardiac arrhythmia. The client needs prompt intervention to improve oxygenation, stabilize the heart rhythm, and treat the infection.

• Statement D is wrong because the chronic health condition of the client (Parkinson’s disease) is not an acute problem that needs immediate attention. However, it is important to monitor the client’s tremors and medication regimen for Parkinson’s disease.
• Statement E is wrong because the current level of consciousness of the client (alert and oriented to self) is not abnormal or concerning. However, it is important to monitor the client’s mental status for any signs of confusion or agitation.
• Statement F is wrong because the tremors of the client are likely related to the Parkinson’s disease and not to the pneumonia. However, it is important to assess the severity and frequency of the tremors and provide comfort measures.

Normal ranges for the vital signs and arterial blood gas are as follows:

• Respiratory rate: 12 to 20 breaths per minute
• Oxygen saturation level: 95% to 100%
• Heart rate: 60 to 100 beats per minute
• Blood pressure: less than 120/80 mmHg
• Temperature: 36.5°C to 37.2°C
• Arterial blood gas: pH 7.35 to 7.45, PaO2 80 to 100 mmHg, PaCO2 35 to 45 mmHg, HCO3 22 to 26 mEq/L

Correct answer is: A, B, and C.

Choice A rationale: Respiratory rate is 28 breaths per minute and labored. This is above the normal range of 12 to 20 breaths per minute and indicates that the client is experiencing respiratory distress. Respiratory distress can lead to hypoxia, tissue damage, and organ failure. Therefore, this finding requires immediate follow-up to improve the client’s oxygenation and ventilation.

Choice B rationale: Oxygen saturation level is 88% on room air. This is below the normal range of 95% to 100% and indicates that the client is hypoxemic. Hypoxemia can result from pneumonia, which causes inflammation and fluid accumulation in the alveoli, impairing gas exchange. Hypoxemia can also cause dysrhythmias, confusion, and cyanosis. Therefore, this finding requires immediate follow-up to administer supplemental oxygen and monitor the client’s response.

Choice C rationale: Heart rate is 110 beats per minute and irregular. This is above the normal range of 60 to 100 beats per minute and indicates that the client has tachycardia and atrial fibrillation. Tachycardia can result from hypoxia, fever, infection, dehydration, or anxiety. Atrial fibrillation is a type of cardiac arrhythmia that causes irregular and rapid contractions of the atria, reducing the cardiac output and increasing the risk of thromboembolism. Therefore, this finding requires immediate follow-up to identify and treat the underlying cause, stabilize the heart rhythm, and prevent complications.

Choice D rationale: Chronic health condition is Parkinson’s disease. This is not an acute problem that requires immediate follow-up. However, it is important to monitor the client’s tremors and medication regimen for Parkinson’s disease, as they can affect the client’s mobility, safety, and quality of life.

Choice E rationale: Current level of consciousness is alert and oriented to self. This is not abnormal or concerning. However, it is important to monitor the client’s mental status for any signs of confusion or agitation, as they can result from hypoxia, infection, or medication side effects.

Choice F rationale: Tremors are in both hands. This is likely related to the Parkinson’s disease and not to the pneumonia. However, it is important to assess the severity and frequency of the tremors and provide comfort measures, such as warm blankets, massage, or relaxation techniques.