An 85-year-old client has had a stroke resulting in right-sided facial drooping, difficulty swallowing, and the inability to move self or maintain position unaided. The nurse determines that which sites are most appropriate for taking the temperature? Select all that apply

Oral

Rectal

Axillary

Tympanic

Temporal artery

Answer and Explanation

Correct Answer : C,D,E

In clients who have had a stroke, especially those with facial drooping, dysphagia (difficulty swallowing), or immobility, the nurse must choose a method of taking temperature that minimizes risk (e.g., aspiration or injury) and provides consistent, accurate readings.

Rationale for correct answer:

C. Axillary: Safe, noninvasive, and easy to perform even in clients with limited mobility. While it is less accurate than core sites, it’s a reasonable alternative when oral and rectal sites are contraindicated.

D. Tympanic: Quick, noninvasive, and reflects core temperature well. Not affected by oral or facial dysfunctions. Can be performed even when the client has limited cooperation.

E. Temporal artery: Noninvasive, fast, and generally well tolerated. Can be used in immobile or neurologically impaired clients without requiring cooperation.

Rationale for incorrect answers:

A. Oral: Oral temperature measurement requires the client to close their mouth tightly around the probe, which is compromised by facial drooping and dysphagia.

B. Rectal: While rectal temperature is accurate, it is invasive and can be uncomfortable, particularly in older or immobile clients.

Take-home points:

Avoid oral and rectal routes in clients with neurologic deficits, swallowing issues, or limited mobility due to safety concerns.
Axillary, tympanic, and temporal artery methods are safe, noninvasive, and appropriate for clients with stroke-related impairments.

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Correct Answer is ["B","E"]

Explanation

A difference in blood pressure readings between arms can be a normal variation (up to 10 mm Hg) or a sign of vascular disease such as subclavian artery stenosis, aortic dissection, or peripheral arterial disease.

Rationale for correct answers:

B. Repeat the measurements on both arms using a stethoscope: The AP may have used an automated cuff, which can be less accurate in obese patients or those with arrhythmias.

E. Review the patient’s record for her baseline vital signs: Comparing with previous BP readings helps determine whether the difference is new, worsening, or chronic.

Rationale for incorrect answers:

A. Notify the health care provider immediately: A 12 mm Hg systolic difference may warrant further evaluation if persistent, but notifying the provider immediately is premature.

C. Ask the patient whether she has taken her blood pressure medications recently: BP medication doesn’t cause a discrepancy between the two limbs.

D. Obtain blood pressure measurements on lower extremities: Lower extremity BP may be needed if there is suspicion of aortic coarctation or severe vascular disease, but this is not routinely indicated for a 12 mm Hg arm difference.

Take-home points:

A systolic BP difference of >10 mm Hg between arms should be manually verified and assessed in context of clinical history and baseline.
Nurses must take a stepwise approach-recheck manually, gather history, review baseline-before escalating to a provider.

A. Cuff too small on the device B. Arm positioned above heart level C. Slow inflation of the cuff by the machine D. Patient did not remove his long-sleeved shirt E. Insufficient time between measurements

Correct Answer is ["A","D","E"]

Explanation

Blood pressure (BP) measurement is a foundational clinical assessment, but its accuracy is highly influenced by technique, cuff size, body position, and external factors.

Rationale for correct answers:

A. Cuff too small on the device: A cuff that is too small for the client’s arm can result in falsely elevated systolic pressure.

D. Patient did not remove his long-sleeved shirt: Taking BP over clothing can interfere with cuff compression and cause falsely high readings, especially thicker or tight sleeves.

E. Insufficient time between measurements: Taking repeat BP readings too soon (e.g., within 1–2 minutes) doesn’t allow time for vascular recovery and can lead to falsely high results.

Rationale for incorrect answers:

B. Arm positioned above heart level: If the arm is above heart level, BP readings tend to be falsely low, not high. To avoid error, the arm should be at heart level.

C. Slow inflation of the cuff by the machine: Slow deflation, not inflation, affects BP accuracy.

Take-home points:

Improper cuff size, measuring over clothing, and not waiting long enough between readings can all cause falsely elevated BP.
BP measurement should be performed with the arm at heart level, cuff directly on skin, and with the correct-sized cuff to ensure accuracy.

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An 85-year-old client has had a stroke resulting in right-sided facial drooping, difficulty swallowing, and the inability to move self or maintain position unaided. The nurse determines that which sites are most appropriate for taking the temperature? Select all that apply

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Naxlex Comprehensive Predictor Exams

During admission of an obese patient with heart failure the assistive personnel (AP) reports to the nurse that the blood pressure (BP) is 140/76 on the left arm and 128/72 on the right arm. What actions do you take on the basis of this information? Select all that apply

Correct Answer is ["B","E"]

Explanation

Correct Answer is ["A","D","E"]

Explanation

A student nurse is learning to assess blood pressure. What does the blood pressure measure?

A 69-year-old woman is admitted with dizziness, confusion, and dyspnea. Which vital sign should not be delegated to trained ancillary personnel?

A client is admitted with a head injury and may develop neurogenic fever. Which nursing diagnosis would be most appropriate for this client?

A patient complains of severe abdominal pain. When assessing the vital signs, the nurse would not be surprised to find what assessment?

An 85-year-old client has had a stroke resulting in right-sided facial drooping, difficulty swallowing, and the inability to move self or maintain position unaided. The nurse determines that which sites are most appropriate for taking the temperature? Select all that apply

It would be appropriate to delegate the taking of vital signs of which client to unlicensed assistive personnel?

For a client with a previous blood pressure of 138/74 mmHg and pulse of 64 beats/min, approximately how long should the nurse take to release the blood pressure cuff in order to obtain an accurate reading?