The nurse needs to measure the adult patient's temperature, but the patient has just finished a cup of coffee. Which is the best type of temperature for the nurse to obtain accurate results efficient-ly?
a. Rectal
b. Axillary
c. Tympanic
d. Disposable
C
The nurse obtains a tympanic temperature because the hot coffee will affect an oral reading. A tympanic temperature is a more reliable indicator of body temperature than the oral reading be-cause a tympanic temperature is a core temperature. Rectal temperatures for adult patients are reserved for occasions when continuous temperature monitoring is required or if no other core temperature site is available; in addition, rectal temperatures are embarrassing for an alert adult patient. Axillary temperatures are not as reliable as tympanic temperatures and do not reflect core temperature. Disposable thermometers are the least accurate method.
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A client has been assigned an admission diagnosis of brief psychotic disorder. Which assessment information would alert the nurse to question this diagnosis?
1. The client has experienced impaired reality testing for a 24-hour period. 2. The client has experienced auditory hallucinations for the past 3 hours. 3. The client has experienced bizarre behavior for 1 day. 4. The client has experienced confusion for 3 weeks.
A nurse is counseling a pregnant cocaine abuser. What should the nurse inform this patient that she is placing her baby at significant risk for?
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Which chest structure contains all the thoracic viscera except the lungs?
a. Manubrium b. Mediastinum c. Sternum d. Xiphoid