A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the skin flushed and warm. Which of the following would be the best method to take the client's body temperature?

Correct Answer: B

Rationale: In the scenario described, the best method to take the client's body temperature is option B) Axillary. This choice is correct because the client's flushed and warm skin indicates a potential fever, and an axillary temperature measurement can provide a reliable estimate of core body temperature. The axillary method is non-invasive, comfortable for the patient, and generally safe. Option A) Oral temperature measurement is not ideal in this case because oral temperatures can be affected by recent ingestion of hot or cold beverages, breathing through the mouth, or oral conditions like inflammation. These factors could lead to inaccurate readings, especially in a client with oral surgery. Option C) Arterial line temperature measurement is an invasive procedure typically used in critical care settings and is not necessary for routine temperature monitoring in a post-surgical client like the one described. Option D) Rectal temperature measurement is generally considered more accurate than axillary temperatures but is invasive and may not be appropriate for this client, especially following oral surgery. Educationally, understanding the rationale behind choosing the appropriate method for taking body temperature is crucial for nursing practice. It ensures accurate assessment and monitoring of a client's health status, which is essential for providing safe and effective care. Nurses must consider factors such as the client's condition, recent interventions, and the most suitable and least invasive method for temperature measurement to ensure optimal patient outcomes.

Correct Answer: B

Rationale: An open structure is loose, and convening a family meeting would give all family members input and an opportunity to express their feelings. Prescribing tasks and delegating care are too rigid for acceptance by a family with an open structure. Speaking to the primary client privately excludes the family.

Correct Answer: C

Rationale: In the assessment of stereognosis, the correct answer is C) A familiar object placed in his hand. Stereognosis refers to the ability to identify objects based on touch and proprioception without the use of vision. By asking the client to identify a familiar object placed in their hand with their eyes closed, the nurse is assessing their tactile perception and cognitive processing abilities. Option A) A number drawn in the palm of his hand assesses graphesthesia, the ability to recognize numbers or letters drawn on the skin. Option B) A word whispered 30 cm from the ear assesses auditory perception and is not relevant to stereognosis. Option D) The vibration of a tuning fork placed on his foot assesses vibratory sense, which is different from stereognosis. In an educational context, understanding the assessment techniques for sensory perception is crucial for nurses to accurately evaluate and care for their patients. By knowing the specific assessment methods for different sensory functions, nurses can identify deficits, provide appropriate interventions, and improve overall patient outcomes.

Correct Answer: A

Rationale: The correct answer is A) Patient sees at 20 feet what the normal sighted person sees at 30 feet. This is because the Snellen eye test measures visual acuity, which is the clarity or sharpness of vision. In the result "20/30," the first number (20) represents the distance at which the test is conducted (20 feet), and the second number (30) represents the distance at which a person with normal vision would be able to see the same line of letters. Therefore, a person with 20/30 vision can see at 20 feet what a person with normal vision can see at 30 feet. Option B is incorrect because it reverses the distances, which would imply that the patient has better vision than normal. Option C and D present distances that are not in line with the standard Snellen eye test format. In an educational context, understanding visual acuity is crucial for nurses as it impacts a patient's ability to perform daily activities, adhere to medication regimens, and maintain overall health. Nurses need to be able to interpret and communicate eye test results effectively to collaborate with other healthcare professionals and provide optimal care for their patients.

Correct Answer: D

Rationale: The correct answer is D) 18th to 19th century. This time period marked the beginning of modern nursing care with the work of Florence Nightingale. Nightingale, known as the founder of modern nursing, revolutionized healthcare by establishing sanitary practices, creating organized training for nurses, and emphasizing the importance of patient care and comfort. Option A) pre-civilization is incorrect because nursing care as we know it today did not exist before organized societies were formed. Option B) early civilization to 16th century is incorrect as nursing during this time was often based on religious or cultural practices rather than the evidence-based care we see in modern nursing. Option C) 16th to 17th century is also incorrect as nursing during this period was still largely informal and lacked the systematic approach introduced by Nightingale in the 18th and 19th centuries. Understanding the historical development of nursing is crucial for nursing students as it provides insight into the evolution of the profession and the factors that have shaped contemporary nursing practice.