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 straightforward 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

The correct answer is choice C. The AP pulls the pinna up and back.

Choice A rationale:

Inserting the probe with a straightforward motion is not sufficient to ensure an accurate reading. Proper positioning of the ear canal is necessary to get an accurate tympanic temperature.

Choice B rationale:

Positioning the client facing the AP is not relevant to the accuracy of the tympanic temperature measurement. The focus should be on the correct technique for inserting the probe.

Choice C rationale:

Pulling the pinna up and back is the correct technique for adults and children over 3 years old. This action straightens the ear canal, allowing for an accurate temperature reading.

Choice D rationale:

Pointing the probe posteriorly is not a standard guideline for taking a tympanic temperature. The probe should be aimed towards the eardrum for an accurate measurement.

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Correct Answer is D

Explanation

The correct answer is D.

Social worker. The rationale is that a social worker can help the client access community resources and transportation services that can facilitate their attendance to follow-up appointments. The social worker can also assess and address any psychosocial barriers that may affect the client's adherence to treatment.

A. Natural loss of deciduous teeth B. Nontender, protruding abdomen C. Head circumference exceeds chest circumference D. Palpable fontanels

Correct Answer is B

Explanation

The correct answer is choice B. Nontender, protruding abdomen.

Choice A rationale:

Natural loss of deciduous teeth typically begins around the age of 6 years, not at 2 years. At 2 years old, toddlers are still in the process of getting their primary teeth.

Choice B rationale:

A nontender, protruding abdomen is a normal finding in toddlers due to their developing abdominal muscles and the typical posture of a toddler.

Choice C rationale:

By the age of 2, a child’s head circumference should no longer exceed their chest circumference. This is a characteristic of infants, not toddlers.

Choice D rationale:

Palpable fontanels are expected in infants. By the age of 2, the anterior fontanel should have closed, making it non-palpable.

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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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