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 points the probe posteriorly.
The AP pulls the pinna up and back.
The AP positions the client facing her.
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Instructing parents to avoid bringing fresh flowers into the room is not the primary intervention for a child with Clostridium difficile. While it is essential to maintain a clean environment, the most critical action is to implement proper infection control measures.
Choice B rationale:
This is the correct answer. Initiating contact precautions is crucial when caring for a child with Clostridium difficile. This includes using gloves and gowns to prevent the spread of the bacteria to others.
Choice C rationale:
Using a HEPA filtration system in the room is not the first-line intervention for managing Clostridium difficile. While it can help maintain air quality, it does not directly address the transmission of the bacteria.
Choice D rationale:
Using an N95 respirator is not the primary action in caring for a child with Clostridium difficile. Contact precautions, such as gloves and gowns, are more critical to prevent the spread of infection.
Correct Answer is A
Explanation
Choice A rationale:
"Nervousness." Rationale: This is a correct instruction. Thyrotoxicosis is a condition characterized by excessive thyroid hormone production. Common symptoms include nervousness, anxiety, restlessness, and emotional instability. The client should notify the healthcare provider if they experience these symptoms as they may indicate an excessive dose of levothyroxine.
Choice B rationale:
"Cough." Rationale: Cough is not typically associated with thyrotoxicosis. Symptoms of thyrotoxicosis are primarily related to an overactive thyroid gland and may include palpitations, weight loss, heat intolerance, and nervousness.
Choice C rationale:
"Pruritus." Rationale: Pruritus (itching) is not a common symptom of thyrotoxicosis. Itchy skin is more likely related to other dermatological or systemic conditions and should be evaluated separately.
Choice D rationale:
"Polyuria." Rationale: Polyuria (excessive urination) can be associated with both hypothyroidism and hyperthyroidism, but it is not a typical manifestation of thyrotoxicosis. Increased urination is more commonly seen in conditions like diabetes mellitus. Therefore, polyuria alone may not be indicative of thyrotoxicosis in this context.
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