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

Maintaining confidentiality and protecting the privacy of clients is a fundamental responsibility of healthcare professionals.

When the nurse becomes aware of a conversation between APs that breaches this confidentiality, it is essential to intervene promptly.

The nurse should approach the APs and respectfully ask them to stop the conversation and remind them about the importance of maintaining client confidentiality.

A. Administer an anti-anxiety medication. B. Explore behaviors that have helped to reduce the client's anxiety in the past. C. Minimize environmental stimuli in the client's surroundings. D. Explain to the client that anxiety causes physical manifestations

Correct Answer is C

Explanation

The client is experiencing palpitations and a sense of impending doom, which may indicate a heightened state of anxiety or a panic attack. Minimizing environmental stimuli can help create a calming and safe environment for the client. By reducing noise, bright lights, and other potentially distressing stimuli, the nurse can create a more soothing atmosphere that may help alleviate the client's anxiety.

While exploring behaviors that have helped to reduce the client's anxiety in the past and explaining to the client that anxiety causes physical manifestations are important actions, they may not provide immediate relief or address the client's immediate distress.

Administering an anti-anxiety medication may be considered if the client's symptoms persist or worsen, but it is not the first action to be taken. The nurse should prioritize non-pharmacological interventions and create a supportive environment before considering medication administration.

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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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