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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. The palm is not the best part of the hand to assess lymph nodes, as it lacks the sensitivity needed for palpation.

B. The parts of the fingers, particularly the pads of the fingers, are used to assess lymph node size. This allows for a more precise and sensitive examination of the lymph nodes.

C. The dorsal side of the hand is not typically used for palpation because it is less sensitive.

D. The ulnar surface of the hand is not commonly used for this purpose, as the fingertips provide better tactile sensation for assessing lymph node size.

Correct Answer is ["A","B","C","E"]

Explanation

A. Erythema (redness) can occur at the site of a gout attack due to inflammation in the affected joint.

B. Hyperuricemia (elevated levels of uric acid in the blood) is a hallmark of gout, leading to the formation of urate crystals.

C. Pain is a prominent symptom of gout, particularly during an acute attack when joints become inflamed and tender.

D. Diarrhea is not a direct complication of gout; it is more associated with gastrointestinal issues or medications.

E. Edema (swelling) can occur in the affected joint due to inflammation associated with gout.

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