A nurse is observing an assistive personnel (AP) take a client's tympanic temperature. Which of the following actions should the nurse identify as an indication that the AP understands how to perform the procedure?
The AP inserts the probe with a straight, forward motion.
The AP positions the client facing her.
The AP pulls the pinna up and back.
The AP points the probe posteriorly.
The Correct Answer is C
Choice A Reason:
Inserting the probe with a straight, forward motion is not correct because the ear canal is curved, and this technique could lead to inaccurate readings or discomfort.
Choice B Reason:
The AP positions the client facing her. The position of the client's face is not relevant to taking a tympanic temperature. The client can face any direction during the procedure.
Choice C Reason:
Pulling the pinna up and back straightens the ear canal in adults, allowing for a more accurate reading when taking a tympanic temperature.
Choice D Reason:
Pointing the probe posteriorly is incorrect as the probe should be pointed towards the tympanic membrane, which usually requires slight angling to align with the ear canal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Illusions typically involve misperceptions of sensory stimuli and can occur in various mental health conditions but are not specific to dementia.
Choice B Reason:
Memory loss that disrupts ADLs is correct. Memory loss that disrupts activities of daily living (ADLs) is a common and characteristic finding in individuals with dementia. Dementia is a progressive neurological disorder that affects cognitive function, including memory. As it progresses, individuals with dementia often experience increasing difficulty with memory and daily functioning.
Choice C Reason:
Pressured speech is a symptom often seen in conditions like mania or bipolar disorder but is not typically associated with dementia.
Choice D Reason:
Catatonia is a neuropsychiatric syndrome that can occur in conditions like schizophrenia but is not a common feature of dementia.
Correct Answer is B
Explanation
Choice A Reason:
Posterior fontanel closed is incorrect, it is normal for the posterior fontanel to close earlier than the anterior fontanel, usually by 2 to 3 months of age.
Choice B Reason:
Anterior fontanel closed is correct. The anterior fontanel is the soft spot on the top of a baby's head, and it typically closes between 12 to 18 months of age. If the anterior fontanel is closed in a 4-month-old infant, it is considered an early closure, which can be a cause for concern. Early closure of the anterior fontanel can be associated with various underlying medical conditions, such as craniosynostosis (premature fusion of the skull bones) or dehydration.
Choice C Reason:
Plays with toes is incorrect. At 4 months of age, infants are typically developing their motor skills, and playing with their toes is a sign of normal development.
Choice D Reason:
Moves objects to mouth is incorrect. At this age, infants often explore their environment by bringing objects to their mouths as part of their sensory exploration and development.
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