The patient requires routine temperature assessment but is confused and easily agitated and has a history of seizures. The nurse's best option would be to take his temperature

a. Orally.
b. Tympanically.
c. Rectally.
d. By the axillary method.


B
The tympanic route is easily accessible, requires minimal patient repositioning, and often can be used without disturbing the patient. It also has a very rapid measurement time. Oral temperatures require patient cooperation and are not recommended for patients with a history of epilepsy. Rectal temperatures require positioning and may increase patient agitation. Axillary temperatures need long measurement times and continuous positioning by the nurse. The patient's agitation state may not allow for long periods of attention.

Nursing

You might also like to view...

Which hormone is responsible for converting the endometrium into decidual cells for implantation?

a. Estrogen b. Human chorionic gonadotropin c. Human placental lactogen d. Progesterone

Nursing

A 15-year-old was referred to the mental health clinic by juvenile court after an arrest for vandalism and assault on a teacher. The teen tells the nurse, "I hate my parents. They focus all attention on my brother, who is perfect in their eyes."

Which nursing diagnosis applies? a. Chronic low self-esteem related to feelings of guilt, as evidenced by believing a brother is the parental favorite b. Hopelessness related to feeling unloved by parents, as evidenced by assaulting a teacher c. Ineffective coping related to seeking parental attention, as evidenced by acting out d. Disturbed personal identity related to acting out, as evidenced by vandalism

Nursing

To meet the learning needs of the older adult, the nurse incorporates which considerations in planning to educate a 73-year-old client with diabetes about insulin administration?

A) requesting hearing aids to help the client receive information B) using numerous handouts and detailed education plan C) allowing more time for the processing of the information D) demonstrating a wide variety of syringes and techniques

Nursing

A nurse, charting the administration of medications to an assigned client at 9 pm, notes that atenolol (Tenormin) was prescribed to be administered at 9 am instead of 9 pm. The nurse checks the client's vital signs, completes an incident report, and calls the physician to report the error. The physician tells the nurse that an incident report is not needed but instructs her to monitor the client during the night for hypotension. What action should the nurse take?

A. Notifying the nursing supervisor B. Tearing up and discarding the incident report C. Telling the physician that the error warrants the completion of an incident report D. Telling the nursing supervisor that the physician did not want an incident report completed and filed

Nursing