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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. Gynecomastia refers to breast tissue enlargement in males and does not typically relate to the menstrual cycle.

B. Cyclic pain refers to breast pain that is linked to the menstrual cycle, commonly occurring before menstruation and subsiding during or after menstruation.

C. Mammary pain is a broader term that may refer to any breast pain, but it does not specify the cyclical nature related to menstruation.

D. Noncyclic pain refers to breast pain not related to the menstrual cycle and does not follow the described pattern.

Correct Answer is B

Explanation

A. A pulse oximeter is used to measure oxygen saturation and is not relevant to cochlear dysfunction.

B. A hearing aid is appropriate for someone with cochlear dysfunction as it can help amplify sound and improve hearing, indicating the client is adapting to the hearing loss.

C. Eyeglasses are used for vision problems and do not relate to the function of the cochlear division of the vestibulocochlear nerve.

D. A bath thermometer is used to measure water temperature and is not relevant to auditory issues.

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