The nurse is assessing orientation in a 79-year-old patient. Which of these responses would lead the nurse to conclude that this patient is oriented?

Correct Answer: D

Rationale: The correct answer is D. This response indicates the patient is fully oriented to person, place, and time. The patient knows their name, location (hospital in Spokane), and the general time frame (February of a new year—2010). Knowing the specific month and year demonstrates a good level of orientation. Choice A is incorrect because the patient is unsure of their location and gives a vague answer about the year. Choice B is incorrect as the patient admits to being confused about the date. Choice C is incorrect because the patient does not know the date, which is an important aspect of orientation.

Correct Answer: B

Rationale: The correct answer is B: Use a Doppler device to check for pulsations. This is the best action because a Doppler device can detect blood flow even when pulses are weak or difficult to palpate. A: Auscultating with a fetoscope is not suitable for assessing pulses. C: Checking for pulsations with a goniometer is used to measure joint angles, not pulses. D: Using a stethoscope to auscultate the pulse may not provide accurate information compared to a Doppler device.

Correct Answer: C

Rationale: The correct answer is C because Standard Precautions are designed to reduce microorganism transmission from all patients, regardless of their infection status. This includes using personal protective equipment (PPE) like gloves, gowns, masks, and face shields when necessary. These precautions are not limited to high-risk patients or specific body fluids; they apply to all patients and all body fluids. Choice A is incorrect because sweat is not considered a high-risk body fluid for transmission of infections. Choice B is incorrect as Standard Precautions are meant for all patients, not just high-risk ones. Choice D is incorrect because gloves are required based on risk assessment, not necessarily for every patient interaction.

Correct Answer: B

Rationale: The correct answer is B: Consider this finding normal in children and young adults. Rationale: 1. This phenomenon is known as respiratory sinus arrhythmia, which is a normal variation in heart rate seen in children and young adults. 2. It occurs due to the physiological response of the autonomic nervous system to changes in intrathoracic pressure during respiration. 3. In children, the heart rate normally speeds up during inspiration and slows down during expiration. 4. Since this is a normal finding, there is no need to notify the physician or consider it as bradycardia. Summary of other choices: A: Not necessary to immediately notify the physician as this is a normal finding. C: Checking the blood pressure is not indicated as the pulse variation with respiration is a separate phenomenon. D: Documenting bradycardia is incorrect as this is not the case here.

Correct Answer: D

Rationale: Correct Answer: D Rationale: 1. In children, the disappearance of phase V Korotkoff sounds is commonly used to determine diastolic blood pressure. 2. Phase V represents the complete cessation of sound, indicating the return of blood flow to normal. 3. This method is preferred over phase IV sounds due to the potential for overestimating diastolic pressure. 4. Utilizing phase V ensures a more accurate diastolic reading in children. Summary of other choices: A: Blood pressure guidelines for children are based on height, not age. B: Phase I Korotkoff sounds indicate the initial appearance of faint tapping sounds, not phase II. C: Doppler devices are not routinely recommended for blood pressure measurements in children.