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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Alcohol withdrawal can often lead to an increase in blood pressure. The autonomic nervous system becomes hyperactive during withdrawal, resulting in increased sympathetic activity, which can elevate blood pressure.

Constipation is not typically associated with alcohol withdrawal. However, chronic alcohol use can affect the gastrointestinal system and lead to digestive issues, including diarrhea or gastrointestinal bleeding.

Polyuria, which refers to excessive urination, is not a typical manifestation of alcohol withdrawal. However, alcohol use can affect fluid balance and lead to changes in urination patterns.

Bradycardia, or a slow heart rate, is not a common manifestation of alcohol withdrawal. Instead, tachycardia (an increased heart rate) is more commonly observed during withdrawal due to the hyperactivity of the autonomic nervous system.

A. Clear rhinorrhea B. Medications for a cardiac anomaly C. Two diarrhea stools in the last day D. Chemotherapy treatments

Correct Answer is D

Explanation

Choice A Reason:

Clear rhinorrhea (runny nose without any other symptoms) is not a contraindication for receiving the varicella vaccine. Contraindications typically involve more serious medical conditions or situations where the vaccine could be harmful.

Choice B Reason:

Medications for a cardiac anomaly. Taking medications for a cardiac anomaly is not a contraindication for the varicella vaccine. In fact, some children with cardiac anomalies may be at higher risk for complications from chickenpox and may benefit from vaccination.

Choice C Reason:

Two diarrhea stools in the last day. Having a couple of episodes of diarrhea in the last day is not a contraindication for the varicella vaccine. Contraindications usually involve more severe or systemic conditions that can affect the safety and effectiveness of the vaccine.

Choice D Reason:

Chemotherapy treatments is correct. A contraindication for receiving a varicella (chickenpox) immunization is undergoing chemotherapy or other immunosuppressive therapies. Children who are immunocompromised should not receive live vaccines like the varicella vaccine because of the risk of developing the disease due to their weakened immune system.

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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?

Nursing Test Bank

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