The nurse is working the night shift on a surgical unit and is making 4 AM rounds. She notices that the patient's temperature is 96.8°F (36°C), whereas at 4 PM the preceding day, it was 98.6°F (37°C). What should the nurse do?

Correct Answer: B

Rationale: In this scenario, option B is the correct choice because the nurse should recognize that a slight variation in temperature (96.8°F at 4 AM compared to 98.6°F at 4 PM the previous day) is within the normal range of diurnal temperature fluctuations. It is important for the nurse to understand that body temperature naturally fluctuates throughout the day, typically being lowest in the early morning and highest in the late afternoon or evening. Calling the physician immediately to report a possible infection (option A) is unwarranted based on this isolated temperature reading and could lead to unnecessary alarm or interventions. Providing another blanket to conserve body temperature (option C) is not appropriate as the patient's temperature is within the normal range. Providing medication to lower the temperature further (option D) is also incorrect as the patient does not have a fever that necessitates pharmacological intervention. Educationally, it is crucial for nurses to have a good understanding of the normal variations in vital signs to avoid unnecessary interventions or alarm. Teaching about diurnal temperature fluctuations and when to be concerned about temperature changes can help nurses provide appropriate care and prevent unnecessary disruptions in patient management. This scenario underscores the importance of clinical judgment and critical thinking in assessing and interpreting vital signs in the healthcare setting.

Correct Answer: A

Rationale: Rationale: The correct action for the nurse to take when assessing a blood pressure of 90/60 mmHg is to document it as normal. In the context of neurological vital signs assessment, a blood pressure of 90/60 mmHg falls within the range of normal for many individuals. It is important for the nurse to interpret vital signs within the broader context of the client's overall health status and their baseline readings. Option B suggests rechecking the blood pressure after 1 hour. While monitoring trends in vital signs is important, in this case, there is no immediate need for a repeat assessment as the blood pressure is within the normal range. Options C and D recommend more invasive interventions such as initiating intravenous fluid therapy or administering a vasopressor medication. These interventions are not warranted for a blood pressure of 90/60 mmHg in the absence of other concerning symptoms or clinical indications. Educationally, it is crucial for healthcare providers to understand the normal ranges for vital signs, as well as when to intervene based on deviations from these norms. This case highlights the importance of clinical judgment and critical thinking in interpreting vital signs accurately to provide safe and effective patient care.

Correct Answer: C

Rationale: Blood pressure is a core vital sign, alongside temperature, pulse, and respiration, reflecting cardiovascular health by measuring arterial force. Mental status is assessed separately, often via neurological exams, not as a vital sign. Visual acuity evaluates eyesight, unrelated to immediate physiological stability. Urinary output monitors kidney function but isn't a standard vital sign, though it's tracked in critical care. The answer key confirms C, aligning with nursing fundamentals (e.g., Taylor's text), where vital signs are immediate indicators of life-sustaining functions, distinguishing BP's role in routine assessments from other metrics.

Correct Answer: A

Rationale: In the context of neurological vital signs assessment, obtaining an accurate core body temperature is crucial for detecting potential neurological issues or abnormalities. The most reliable site for measuring core body temperature is the rectal site (Option A). Rectal temperature closely reflects core body temperature because it is in close proximity to internal organs where heat is produced and regulated. This makes it the preferred site for accurate temperature assessment, especially in critically ill patients or those with neurological conditions where even slight changes in temperature can be significant indicators of health status. Oral temperature (Option B) can be influenced by factors like drinking hot or cold liquids, breathing through the mouth, or recent smoking, leading to less reliable results compared to rectal measurements. Axillary temperature (Option C) tends to be lower than core body temperature due to the distance from internal organs, making it less accurate for assessing core body temperature in neurological conditions. Forehead temperature (Option D) is not a reliable measure of core body temperature as it reflects surface temperature rather than internal temperature, making it unsuitable for accurate neurological vital signs assessment. Educationally, understanding the rationale behind selecting the appropriate temperature measurement site is essential for healthcare professionals to provide optimal care and make informed clinical decisions, especially in neurological assessments where precision and accuracy are paramount.

Correct Answer: B

Rationale: In a neurological vital signs assessment, the correct answer to the question of which position should not be used to assess the abdomen is B) dorsal recumbent. The dorsal recumbent position, where the patient lies on their back with knees bent and feet flat on the bed, is not ideal for abdominal assessment in a neurological context because it does not allow for optimal visualization and palpation of the abdomen. The supine position (option A) is commonly used for abdominal assessments as it allows for a full view and palpation of the abdomen. The kneechest position (option C) is used to assess the rectal area and is not typically used for abdominal assessment. The Sims position (option D) is often used for rectal examinations but can also be used for assessing the abdomen, as it allows for better visualization and palpation of the abdominal organs. In an educational context, understanding the appropriate positions for assessing different body areas is crucial for healthcare providers to accurately assess patients and gather important clinical information. Proper positioning not only ensures thorough assessments but also promotes patient comfort and safety. It is essential for healthcare professionals to be knowledgeable about the rationale behind positioning choices to provide effective patient care.