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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?

A.

Temperature

B.

Respirations

C.

Blood pressure

D.

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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Correct Answer is B

Explanation

A. Observing for facial symmetry assesses cranial nerves VII (facial nerve) rather than cranial nerve III.

B. Checking the pupillary response to light assesses cranial nerve III (oculomotor nerve), which controls pupil constriction and extraocular eye movements.

C. Testing visual acuity assesses cranial nerve II (optic nerve), not cranial nerve III.

D. Eliciting the gag reflex assesses cranial nerves IX (glossopharyngeal) and X (vagus), not cranial nerve III.

Correct Answer is B

Explanation

A. Lordosis is an exaggerated inward curvature of the lumbar spine.


B. Scoliosis is a lateral curvature of the spine, often characterized by an "S" or "C" shape when viewed from behind. This is the disorder depicted in the image.


C. Kyphosis is an exaggerated outward curvature of the thoracic spine, often leading to a hunchback appearance.


D. Funnel chest (pectus excavatum) is a condition where the breastbone sinks into the chest, creating a sunken appearance.

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