A nurse is assessing a client's body temperature and notices shivering and goosebumps. What action should the nurse take?

Correct Answer: A

Rationale: Shivering and goosebumps indicate the body is raising its temperature, likely due to cold. Warm blankets prevent heat loss and enhance comfort. Antipyretics treat fever, not applicable here. Cool compresses worsen heat loss. Notifying the provider is unnecessary for a normal response. Choice A is correct, per the explanation, reflecting nursing's role in supporting thermoregulation during hypothermia or chills.

Correct Answer: C

Rationale: In the context of a patient in shock with increased carbon dioxide and decreased oxygen levels in arterial blood gases, the nurse would expect to assess rapid and deep respirations (Option C). This is because the body is attempting to compensate for the inadequate oxygenation by breathing more rapidly to increase oxygen intake and deeper to improve gas exchange. Option A (absent and infrequent) is incorrect because in shock, the body typically responds with increased respiratory effort rather than reduced or absent breathing. Option B (shallow and slow) is also incorrect as shallow breathing would not effectively improve oxygenation in a patient experiencing shock. Option D (noisy and difficult) is not characteristic of the respiratory pattern associated with compensatory mechanisms in shock. Educationally, it is important for nurses to understand the physiological responses of the body to various pathophysiological conditions, such as shock. Recognizing the patterns of respiratory distress and understanding the underlying mechanisms can guide nursing interventions and aid in prompt and effective patient care. This knowledge is crucial in providing timely and appropriate respiratory support to patients in critical conditions.

Correct Answer: C

Rationale: In the context of vital signs assessment and hypertension education, selecting answer choice C, "No, a single BP reading should not be used," as the correct option is crucial. This choice is correct because a single blood pressure reading, such as 150/92, is not enough to diagnose hypertension or initiate patient education on the condition. Educationally, it is essential to understand that hypertension diagnosis requires multiple blood pressure readings taken at different times to establish a pattern of elevated blood pressure consistently. Educating patients on hypertension based on a single reading could lead to unnecessary anxiety, interventions, or treatments. Regarding the other options: A) "It depends on the time of day the BP was taken" is incorrect because regardless of the time of day, a single reading is insufficient for a hypertension diagnosis. B) "It depends on whether the patient is male or female" is incorrect as gender does not determine the need for hypertension education; accurate diagnosis does. D) "Yes, this reading is high enough to be significant" is incorrect because significance in hypertension diagnosis is based on multiple readings over time, not a single elevated reading. In summary, understanding the importance of multiple readings in diagnosing hypertension and initiating appropriate patient education is crucial in the context of vital signs assessment. It is vital to emphasize the need for accurate and consistent monitoring before drawing conclusions or providing education on hypertension based on one reading.

Correct Answer: A

Rationale: The correct answer is option A) decreased color vision and peripheral vision. In the older adult population, physiological changes occur in the eyes and ears due to the aging process. These changes can impact sensory functions, such as vision and hearing. Decreased color vision and peripheral vision are common age-related changes that affect older adults. Color vision tends to diminish with age due to changes in the lens and retina, while peripheral vision may decrease due to conditions like glaucoma or other age-related eye diseases. Option B) increased adaptation to light and dark is incorrect because older adults often experience a decreased ability to adapt to changes in light and dark environments. This is due to changes in the pupil's response to light and the overall decrease in visual acuity that comes with aging. Option C) a blue ring around the cornea (arcus senilis) is incorrect because arcus senilis is a condition where a grayish-white ring forms around the cornea, not a blue ring. This condition is more commonly seen in older adults but is not a universal occurrence. Option D) entropion and ectropion are incorrect as they refer to eyelid conditions where the eyelid either turns inward (entropion) or outward (ectropion). While these conditions can occur in older adults, they are not specific to head and neck variations in the older adult population. Educationally, it is essential for healthcare providers, especially nurses, to understand the normal age-related changes that occur in older adults to provide appropriate care and address any potential health issues promptly. By recognizing these variations, nurses can better assess, monitor, and intervene to maintain the health and well-being of older adult residents in long-term care facilities.