The nurse is performing a neurological assessment and asks the patient to walk heel-to-toe. The patient staggers and loses balance. What does this finding suggest?

Correct Answer: A

Rationale: The correct answer is A: Cerebellar dysfunction. When a patient staggers and loses balance while walking heel-to-toe, it indicates impairment in coordination and balance control, which are functions of the cerebellum. The cerebellum plays a crucial role in coordinating voluntary movements and maintaining balance. Vestibular dysfunction (B) primarily affects the inner ear's balance system, leading to vertigo and dizziness, not staggering gait. Sensory neuropathy (C) affects sensation, not coordination, and would not cause a specific gait abnormality. Motor weakness (D) would manifest as difficulty with strength and muscle control, not coordination issues seen in cerebellar dysfunction.

Correct Answer: B

Rationale: Vital signs include measurable indicators like pulse, temperature, blood pressure, and sometimes pain, but the question Surface and Core specifically refers to temperature, making Choice B correct. Temperature can be measured at surface sites (e.g., skin, oral) or core sites (e.g., rectal, tympanic), reflecting internal body heat. Pulse, measures heart rate, not divided into surface and core. Blood pressure, assesses vascular pressure, not temperature distribution. Pain, is subjective and not measured in this dual context. The distinction between surface (less stable, affected by environment) and core (stable, reflecting true body temperature) is a key concept in nursing, especially when monitoring fever or hypothermia. Thus, B aligns with the questions focus on temperatures dual measurement nature.

Correct Answer: D

Rationale: Afebrile means the patient has no fever, indicating a temperature within the normal range for an adult (typically 36.6°C to 38°C or 97.9°F to 100.4°F). When a nurse records a patient as afebrile, it suggests the absence of an elevated temperature that would require intervention. Choice A (checking for antipyretics) is unnecessary unless theres evidence of recent fever management, which isnt indicated here. Choice B (reporting to the provider) is not warranted for a normal finding unless other symptoms suggest a need for escalation. Choice C (using a different method) is redundant since the oral method is reliable and the result is normal. Choice D is correct because no further action is needed for a temperature within normal limits. This reflects standard nursing practice where routine findings dont prompt additional steps unless contextual factors suggest otherwise.

Correct Answer: B

Rationale: Radiant heaters regulate infant temperature safely. A bony area probe is incorrect; it's placed on soft tissue (e.g., abdomen). Warming blankets first ensures comfort and gradual warming, a recommended step. An uncovered probe is true but less critical than B. Manual adjustment every 15 minutes risks instability; servo-control is preferred. Choice B is correct as pre-warming blankets aligns with guidelines (e.g., AAP) to prevent cold stress, enhancing safety and effectiveness in neonatal thermoregulation.

Correct Answer: C

Rationale: Post-cardiac arrest, tympanic provides a quick, non-invasive core temperature estimate, critical for monitoring hypothermia or hyperthermia in resuscitation. Oral risks inaccuracy post-arrest. Rectal is invasive and slow. Temporal is less reliable in emergencies. Choice C is correct, aligning with ACLS emphasis on rapid, safe temperature assessment.