77 mm Hg. Which vital sign should the nurse re-measure?

Temperature

Respirations

Blood pressure

Heart rate

Answer and Explanation

The Correct Answer is D

A. The tympanic temperature of 37.1° C (98.8° F) is within normal limits and does not require re-measurement.

B. The respiratory rate of 14/min is also within the normal range (12-20 breaths per minute).

C. The blood pressure of 98/77 mm Hg is not alarmingly low and does not require immediate re-measurement.

D. A pulse rate of 42/min indicates bradycardia (normal resting heart rate is typically between

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A. heroin B. ecstasy C. cocaine D. marijuana

Correct Answer is C

Explanation

A. Heroin use is generally associated with intravenous use and is less commonly linked to nasal septum perforation.

B. Ecstasy (MDMA) is primarily used in tablet form and is not typically associated with nasal use that would cause septal perforation.

C. Cocaine is frequently snorted, which can lead to irritation and damage to the nasal passages and septum, resulting in perforation.

D. Marijuana is usually smoked rather than snorted, and it is not commonly associated with nasal septum perforation.

A. Ask the client to identify scented aromas. B. Ask the click to read a Snellen chart. C. Listen to the client's speech. D. Ask the client to clench his teeth.

Correct Answer is A

Explanation

A. Asking the client to identify scented aromas assesses cranial nerve I (olfactory nerve), which is responsible for the sense of smell.

B. Reading a Snellen chart assesses cranial nerve II (optic nerve), which is related to vision.

C. Listening to the client's speech evaluates the function of cranial nerves V (trigeminal) and XII (hypoglossal), which are related to mastication and tongue movement, respectively.

D. Asking the client to clench his teeth tests cranial nerve V, which innervates the muscles of mastication.

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An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 42/min, respiratory rate 14/min, and BP 98/77 mm Hg. Which vital sign should the nurse re-measure?

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Correct Answer is C

Explanation

Correct Answer is A

Explanation

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Take full exam for free An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 42/min, respiratory rate 14/min, and BP 98/77 mm Hg. Which vital sign should the nurse re-measure?

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Mr. Sprat is a 21-year-old patient who complains of nasal congestion. He admits to using recreational drugs. On examination, you have noted a septal perforation. Which recreational drug is commonly associated with nasal septum perforation?

Correct Answer is C

Explanation

A nurse is assessing a client's cranial nerves. Which method should the nurse use to assess cranial nerve I?

Correct Answer is A

Explanation

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An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 42/min, respiratory rate 14/min, and BP 98/77 mm Hg. Which vital sign should the nurse re-measure?