The client has been hospitalized after a severe closed head injury and has erratic tympanic temperatures. Which is the most likely cause of the client's abnormal temperature fluctuations?
1. Measuring variations by the nursing assistant
2. Increased loss of client heat from vasodilation
3. Evaluating the vital signs at four-hour intervals
4. Increased intracranial pressure on hypothalamus
1
1. The most likely causes of the erratic temperatures are variations in the nursing as-sistant's technique resulting in a high percentage of abnormal results. Proper tech-nique includes pulling the pinna of the ear back, up, and out for an adult; then the nurse inserts the tympanic probe into the ear, making a figure-eight pattern and posi-tioning the tip toward the tip of the nose.
2. Vasodilation is not a common result of a closed head injury.
3. Taking the temperature every 4 hours is common practice in hospitals and is per-formed to identify sustained abnormal temperatures because the normal body tem-perature normally fluctuates during a 24-hour period.
4. If increased intracranial pressure was the cause of the temperature fluctuations, it is much more likely that the temperature would be at a sustained, abnormal point or trending up or down.
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