A 75-year-old client has a baseline oral temperature of 96.8° F (36° C). Two hours later the client’s oral temperature is 100.8° F (38.2° C).
Which action should a nurse take next?

Notify the health care provider to report and anticipate new orders.

Cover the client with an additional blanket & alert the UAP to recheck in two hours.

Chart the temperature on the vital signs sheet and report to the new shift coming on.

Assess the client’s temperature rectally and compare the results.

Answer and Explanation

The Correct Answer is A

Notify the health care provider to report and anticipate new orders.

This is because an oral temperature of 100.8° F (38.2° C) indicates a fever, which could be a sign of infection or inflammation in an elderly client.

A fever of this magnitude could also cause dehydration, confusion, or seizures in older adults.

Therefore, the nurse should notify the health care provider as soon as possible to determine the cause and treatment of the fever.

Choice B is wrong because covering the client with an additional blanket could increase the body temperature and worsen the fever.

The UAP should not recheck the temperature in two hours, but rather monitor it more frequently and report any changes to the nurse.

Choice C is wrong because charting the temperature on the vital signs sheet and reporting to the new shift coming on is not enough to address the urgency of the situation.

The nurse has a responsibility to act on abnormal findings and communicate them to the health care provider.

Choice D is wrong because assessing the client’s temperature rectally and comparing the results is not necessary and could cause discomfort or injury to the client.

Rectal temperatures are usually higher than oral temperatures by about 0.5° F (0.3° C), so this would not change the interpretation of the fever.

The normal range for oral temperature in adults is 97.6° F to 99.6° F (36.4° C to 37.6° C).

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Correct Answer is B

Explanation

The client practices meditation for 20 minutes once a day. This is an example of an adaptive coping strategy, which is a cognitive or behavioral effort to manage stressful conditions or associated emotional distress.

Meditation can help reduce tension, enhance relaxation, and promote well-being.

Choice A is wrong because the client consumes 3 glasses of wine after a stressful day at work. This is an example of an avoidance coping strategy, which is an attempt to reduce stress by avoiding dealing directly with the problem.

Alcohol consumption can have negative effects on physical and mental health, and does not address the source of stress.

Choice C is wrong because the client keeps all unresolved conflict to themselves. This is an example of an emotion-focused coping strategy, which is an attempt to regulate the emotional distress caused by a stressor.

However, this strategy can be maladaptive if it involves suppressing or denying emotions, which can lead to increased psychological distress and poor interpersonal relationships.

Choice D is wrong because the client consumes a half gallon of ice cream after an argument with a coworker. This is another example of an avoidance coping strategy, which is an attempt to reduce stress by avoiding dealing directly with the problem.

Ice cream consumption can have negative effects on physical health, such as obesity and diabetes, and does not address the source of stress.

A. The client uses the walker to get up from the chair and looks down at his feet to prevent falling. B. The client bears weight on both feet when moving the walker ahead and steps with the weaker leg first. C. The client places her full weight on the walker with her arms while taking steps to prevent pressure on her lower extremity joints. D. The client leans forward at a 60-degree angle while stepping into the walker but looks ahead at where he is going.

Correct Answer is B

Explanation

The client bears weight on both feet when moving the walker ahead and steps with the weaker leg first. This is the proper way to use a walker for ambulation, as it provides stability and reduces stress on the affected joints.

Choice A is wrong because the client should not look down at his feet to prevent falling, but rather look ahead at where he is going. Looking down can cause neck strain and loss of balance.

Choice C is wrong because the client should not place her full weight on the walker with her arms while taking steps, as this can cause upper extremity fatigue and injury. The client should use the walker as a support, not a crutch.

Choice D is wrong because the client should not lean forward at a 60-degree angle while stepping into the walker, as this can cause back pain and poor posture. The client should stand upright and move the walker forward about one step’s length at a time.

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A 75-year-old client has a baseline oral temperature of 96.8° F (36° C). Two hours later the client’s oral temperature is 100.8° F (38.2° C). Which action should a nurse take next?

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A 75-year-old client has a baseline oral temperature of 96.8° F (36° C). Two hours later the client’s oral temperature is 100.8° F (38.2° C).
Which action should a nurse take next?