The client has been hospitalized after a severe head injury. The nurse recognizes that the client's difficulty in maintaining a normal body temperature when there is no infection present can be the result of which of these?

Errors by the nurse assistant in measuring temperature

Increased vasodilatation of the superficial vessels contributing to excess heat losses

The client's head injury causing interference with the function of the hypothalamus

Choosing the wrong time of day to obtain vital signs

Answer and Explanation

The Correct Answer is C

A. Errors by the nurse assistant in measuring temperature. While improper technique can lead to inaccurate readings, consistent temperature fluctuations in a head injury patient are more likely due to hypothalamic dysfunction.
B. Increased vasodilatation of the superficial vessels contributing to excess heat losses. Vasodilation can play a role in heat loss, but it does not fully explain difficulty maintaining body temperature, which is primarily regulated by the hypothalamus.
C. The client's head injury causing interference with the function of the hypothalamus. The hypothalamus regulates body temperature, and a severe head injury can disrupt this function, leading to temperature instability (neurogenic fever or hypothermia) despite the absence of infection.
D. Choosing the wrong time of day to obtain vital signs. While body temperature naturally fluctuates throughout the day, major instability in temperature regulation is not due to the timing of measurement but rather an issue with the hypothalamus.

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Correct Answer is A

Explanation

A. Apical. The apical pulse, located at the apex of the heart, provides the most accurate measurement of heart rate, especially in patients with irregular rhythms. It is assessed by auscultation with a stethoscope over the fifth intercostal space at the midclavicular line.
B. Radial. The radial pulse is commonly used for routine pulse checks, but it may be less accurate in cases of irregular heart rhythms or weak peripheral circulation.
C. Brachial. The brachial pulse is typically used in infants and for blood pressure measurements, but it is not the most accurate method for assessing heart rate.
D. Popliteal. The popliteal pulse is located behind the knee and is used to assess circulation to the lower extremities, not for measuring heart rate accurately.

A. Always take the patient's blood pressure manually using a sphygmomanometer. B. Monitor the patient's neurological status carefully for symptoms of a stroke. C. Assist the patient to sit and stand slowly when getting out of bed. D. Check the patient's blood pressure on a lower extremity using a thigh-sized cuff.

Correct Answer is C

Explanation

A. Always take the patient's blood pressure manually using a sphygmomanometer. While manual BP measurements can be more accurate, they are not the priority intervention for orthostatic hypotension, which primarily involves position changes and fall prevention.
B. Monitor the patient's neurological status carefully for symptoms of a stroke. Orthostatic hypotension can cause dizziness or fainting, but it is not a direct cause of stroke. Neurological assessment is important if symptoms arise but is not the primary intervention.
C. Assist the patient to sit and stand slowly when getting out of bed. Orthostatic hypotension causes a sudden drop in blood pressure upon standing, increasing the risk of falls and syncope. The priority action is to help the patient transition slowly from lying to sitting and standing to allow the body to adjust.
D. Check the patient's blood pressure on a lower extremity using a thigh-sized cuff. Lower extremity BP measurements are not standard for managing orthostatic hypotension. Blood pressure should be checked in both lying, sitting, and standing positions to monitor for significant drops.

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The client has been hospitalized after a severe head injury. The nurse recognizes that the client's difficulty in maintaining a normal body temperature when there is no infection present can be the result of which of these?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which method will provide the most accurate measurement of the patient's heart rate?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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