The young mother of an 8-month-old patient brought her daughter to the clinic after taking the little girl's temperature rectally and obtaining a reading of 100.4 F. The mother was concerned that her daughter might be ill. Which of the following is the best response?
"When taking multiple temperature, the sites should be rotated."
"Because of her age, it is probably a bacterial infection."
"Children usually run lower rather than higher temperatures when ill."
"Rectal temperature readings are higher than temperature obtained orally."
The Correct Answer is D
A. "When taking multiple temperatures, the sites should be rotated.":
This does not address the mother’s concern about the specific temperature reading and its significance.
B. "Because of her age, it is probably a bacterial infection.":
A temp of 100.4°F is low-grade and not diagnostic of bacterial infection, especially in an infant without other symptoms.
C. "Children usually run lower rather than higher temperatures when ill.":
Children often run higher fevers when ill, not lower.
D. "Rectal temperature readings are higher than temperature obtained orally.":
Rectal temperatures are typically 0.5°F to 1°F higher than oral readings. A rectal temp of 100.4°F is considered the threshold for fever in infants but may still be within normal for a well-appearing child.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Massage reddened areas during dressing changes:
Massaging reddened or compromised skin can worsen tissue damage and increase the risk of further injury.
B. Apply a heat lamp twice a day:
Heat lamps are not recommended and may dry out the wound bed or burn healing tissue.
C. Cleanse with 0.9% sodium chloride irrigation:
Normal saline is gentle and effective for cleaning granulating tissue without causing damage or cytotoxic effects.
D. Cleanse with povidone-iodine solution:
Povidone-iodine is cytotoxic and can impair wound healing, especially to new granulating tissue.
Correct Answer is C
Explanation
A. Temperature of 39°C (102.2°F):
Fever typically causes an increase in heart rate, not bradycardia.
B. Hypoglycemia:
Hypoglycemia is more commonly associated with tachycardia, sweating, and tremors, not bradycardia.
C. Report of dizziness:
Bradycardia (HR <60/min) can lead to decreased cardiac output and cerebral perfusion, causing dizziness.
D. History of cigarette smoking:
Smoking is associated with cardiovascular disease but not specifically bradycardia.
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