A nurse is assessing a client who has an oral temperature of 39 C (102.27 F). Which of the following findings should the nurse expect?

Decreased peripheral pulses

Heart rate 108/min

Respiratory rate 10 breathes/min

Dilated pupils

Answer and Explanation

The Correct Answer is B

A) Decreased peripheral pulses:
Increased body temperature typically causes vasodilation rather than vasoconstriction, leading to improved blood flow rather than decreased. As a result, peripheral pulses are more likely to be normal or even increased in response to fever. Decreased peripheral pulses would be more indicative of conditions like shock or hypoperfusion, not fever.

B) Heart rate 108/min:
Fever causes an increase in metabolic demand, which often results in a compensatory increase in heart rate (tachycardia). This phenomenon, known as "fever tachycardia," occurs as the body attempts to circulate blood more rapidly to meet the increased oxygen and nutrient demands caused by elevated body temperature. A heart rate of 108 beats per minute is a normal response to fever, particularly when the temperature reaches 39°C (102.27°F).
C) Respiratory rate 10 breaths/min:
A respiratory rate of 10 breaths per minute is considered bradypnea (abnormally slow breathing), which is typically not associated with fever. Fever usually leads to an increase in respiratory rate (tachypnea) as the body attempts to cool itself through increased evaporation of sweat and breathing. A respiratory rate of 10 breaths/min is more likely to be seen in conditions like drug overdose, head injury, or respiratory depression, rather than fever.
D) Dilated pupils:
Dilated pupils (mydriasis) are typically associated with sympathetic nervous system activation, which can be caused by certain drugs, trauma, or neurological conditions. Fever, however, generally causes only mild changes in pupil size and is more likely to lead to constricted pupils (miosis) in response to certain stress hormones. Dilated pupils are not a typical finding with fever.

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Correct Answer is A

Explanation

A) Memory loss:
Zolpidem, a sedative-hypnotic commonly prescribed for insomnia, can cause memory problems, including short-term memory loss. This is a known adverse effect of zolpidem, especially when taken in higher doses or when a person is not able to get a full night’s sleep after taking the medication. This side effect can manifest as amnesia or difficulty recalling events that occurred while under the influence of the medication.

B) Dry mouth:
While dry mouth is a common side effect of many medications, including some antihistamines and antidepressants, it is not a typical or major adverse effect associated with zolpidem. Though less common, it may occur in some individuals, but it is not considered a primary or significant adverse effect of this drug.

C) Hypertension:
Zolpidem does not typically cause hypertension. In fact, it is more likely to cause a calming effect that may lead to a decrease in blood pressure, particularly in individuals who experience sedation. It is important for the nurse to monitor for any unusual changes in vital signs, but hypertension is not a known adverse effect of zolpidem.

D) Urinary retention:
Urinary retention is more commonly associated with medications that affect the autonomic nervous system, such as antihistamines, anticholinergics, or certain opioids. Zolpidem is not typically associated with urinary retention. While any sedative could potentially cause mild disruptions in normal bladder function due to its sedative properties, urinary retention is not a frequent or well-known side effect of zolpidem.

A. Describe the steps of walking with crutches for the client B. Encourage the client to ask questions about walking with crutches C. Show the client a video on walking with crutches D. Ask the client to demonstrate walking with crutches

Correct Answer is D

Explanation

A) Describe the steps of walking with crutches for the client:
Describing the steps of walking with crutches involves cognitive learning, where the focus is on understanding and acquiring knowledge. In this case, the nurse is providing verbal information to the client about how to use crutches, but this does not engage the psychomotor domain, which involves the physical performance of tasks or skills.

B) Encourage the client to ask questions about walking with crutches:
Encouraging questions is part of the affective domain of learning, which focuses on attitudes, feelings, and the ability to value or appreciate information. By encouraging the client to ask questions, the nurse is promoting understanding and engagement, but this is not related to the psychomotor domain, which requires physical action or skill development.

C) Show the client a video on walking with crutches:
Showing a video involves cognitive learning as it provides the client with visual information and demonstrations. While this helps with understanding how to walk with crutches, it is still a passive form of learning where the client is watching but not physically engaging with the task.

D) Ask the client to demonstrate walking with crutches:
Asking the client to demonstrate walking with crutches directly involves the psychomotor domain of learning, which is concerned with the physical act of performing tasks or skills. By demonstrating how to walk with crutches, the client is actively engaging in the skill, allowing for hands-on practice and the development of muscle memory.

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A nurse is assessing a client who has an oral temperature of 39 C (102.27 F). Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has a new prescription for zolpidem. The nurse should instruct the client that which of the following is an adverse effect of zolpidem?

Correct Answer is A

Explanation

A nurse is teaching a client how to use crutches. Which of the following interventions uses the psychomotor domain of learning?

Correct Answer is D

Explanation

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