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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Pneumonia typically causes fever, tachypnea, increased heart rate, and reduced oxygen saturation. Treatment goals include reducing fever and infection, improving oxygenation, and relieving respiratory distress.
Rationale for correct answers:
A. Temperature: 37°C (98.6°F): This indicates that the fever has resolved, showing the antibiotics may be working and inflammation is decreasing.
B. Radial pulse: 98: The heart rate decreased from 112 to 98 bpm, reflecting reduced sympathetic response (less fever, improved oxygenation).
C. Respiratory rate: 18: A drop from 22 to 18 breaths/min indicates eased breathing, improved oxygen exchange, and reduced respiratory distress.
D. Oxygen saturation: 96%: An increase from 94% to 96% on 2 L oxygen suggests better gas exchange and alveolar function.
Rationale for incorrect answers:
E. Blood pressure: 134/78: Clinically stable but not the best indicator of pneumonia recovery. BP has remained within the normal range and is slightly lower than baseline (138/82).
Take-home points:
- Positive treatment outcomes in pneumonia include lowered fever, normalized respiratory rate, improved oxygen saturation, and decreasing heart rate.
- While blood pressure stability is important, it is less specific for tracking pneumonia recovery compared to respiratory and oxygenation parameters.
Correct Answer is B
Explanation
Accurate blood pressure (BP) measurement is a fundamental nursing skill. If the cuff is deflated too quickly, the nurse may miss the first Korotkoff sound (systolic BP) or inaccurately estimate diastolic pressure. Deflating the cuff too slowly can cause venous congestion, discomfort, and a falsely high diastolic reading. Best practice guidelines recommend a cuff deflation rate of 2–3 mmHg per second to ensure an accurate reading without patient discomfort.
Rationale for correct answer:
B. 30–45 seconds: This is the recommended time frame for releasing the cuff when using a 2–3 mmHg/second deflation rate, which allows clear identification of both systolic and diastolic sounds.
Rationale for incorrect answers:
A. 10–20 seconds: Deflating the cuff this quickly equates to a deflation rate that is too fast (greater than 5 mmHg per second). This may result in missing Korotkoff sounds and underestimating the true BP values, especially systolic pressure.
C. 1 -- A.5 minutes: Deflating the cuff this slowly would equate to less than 1 mmHg per second, which is unnecessarily prolonged. It can cause venous congestion, discomfort, and may lead to a falsely elevated diastolic pressure.
D. 3–C.5 minutes: This is excessively slow and not clinically appropriate.
Take-home points:
- The blood pressure cuff should be deflated at a rate of 2-3 mmHg per second, resulting in a total release time of approximately 30-45 seconds, depending on the pressure range.
- Incorrect deflation rates (too fast or too slow) can lead to inaccurate readings and impact clinical decisions.
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