A nurse is assessing a client's body temperature. Which route provides the most accurate measurement of core body temperature?

Correct Answer: D

Rationale: The rectal route is the most accurate for core body temperature, reflecting blood perfusing the hypothalamus, the body's thermoregulatory center. Oral is convenient but affected by intake or breathing, reducing precision. Axillary is non-invasive but underestimates core temperature by about 1°F due to external influences. Temporal is quick yet less accurate than rectal, as it measures surface arterial flow, not deep core temp. Choice D is correct, per the explanation and nursing standards (e.g., Potter & Perry), as rectal readings closely align with internal physiology, making it the gold standard for critical assessments despite its invasiveness.

Correct Answer: D

Rationale: Convection involves heat loss via air movement (e.g., a fan), per the answer key. Evaporation is sweat-based cooling. Radiation is heat emission without contact. Conduction requires direct touch. The fan enhances air circulation, speeding heat loss from the skin, a key nursing intervention for overheating, aligning with physiological principles of heat transfer in patient comfort management.

Correct Answer: D

Rationale: The correct answer is D) Not all of the heartbeats are reaching the periphery. When a pulse deficit is identified during an apical-radial pulse assessment, it indicates that there is a variance between the number of heartbeats (apical pulse) and the number of pulses felt at the periphery (radial pulse). This discrepancy suggests that not all heartbeats are being effectively transmitted to the peripheral arteries, which can be due to conditions like arrhythmias or heart failure. Option A) The radial pulse is more rapid than the apical pulse is incorrect because a pulse deficit specifically refers to a difference in the apical and radial pulses, not the rate of one being faster than the other. Option B) This is a normal finding and should be ignored is incorrect because a pulse deficit is not a normal finding and warrants further investigation and evaluation. Option C) The patient's arteries are very compliant is incorrect because arterial compliance does not directly relate to the presence of a pulse deficit during an apical-radial pulse assessment. In an educational context, understanding the significance of a pulse deficit is crucial for healthcare professionals in assessing cardiovascular function accurately. Recognizing and interpreting a pulse deficit can prompt timely interventions and further diagnostic evaluations to address underlying cardiac issues.

Correct Answer: A

Rationale: In the context of a general survey of a patient admitted to the hospital, taking vital signs is a crucial element. Vital signs provide essential information about the patient's physiological status, helping the nurse establish a baseline and monitor changes in health. This assessment includes measurements like temperature, blood pressure, heart rate, and respiratory rate, which are fundamental in detecting deviations from normal and guiding further interventions. Palpating the integument (option B) involves assessing the skin for temperature, moisture, texture, and turgor, which is indeed an important part of the physical examination but not specifically part of the general survey. Identifying risk factors for altered health (option C) is a vital nursing assessment skill, but it is more related to obtaining the patient's history and conducting a comprehensive health assessment rather than being a direct component of a general survey. Assessing the head and neck (option D) is also an essential nursing assessment component, focusing on specific body areas rather than the overall survey of the patient upon admission. Understanding the distinction between these assessment components is crucial for nurses to prioritize and conduct a comprehensive evaluation of the patient's health status systematically. This rationale emphasizes the significance of vital signs as a foundational element in the initial assessment process of a patient admitted to the hospital.