A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement?
Measure temperature at regular intervals.
Assess for flushed, warm skin regularly.
Vary sites for temperature measurement.
Document the client's circadian rhythms.
The Correct Answer is A
Choice A Reason: This is correct because measuring temperature at regular intervals allows the nurse to monitor fever patterns and evaluate the effectiveness of interventions.
Choice B Reason: This is incorrect because assessing for flushed, warm skin regularly is not a reliable indicator of fever. Skin temperature may vary depending on environmental factors and blood flow.
Choice C Reason: This is incorrect because varying sites for temperature measurement may result in inaccurate readings. Different sites have different normal ranges and may be affected by external factors.
Choice D Reason: This is incorrect because documenting the client's circadian rhythms is not relevant to assessing fever patterns. Circadian rhythms are natural fluctuations in body functions that occur over a 24-hour cycle.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because contacting the healthcare provider about the frequency of pain medication is a dependent intervention that requires an order from the provider. The nurse should first use independent interventions such as reviewing available prescriptions or providing non-pharmacological measures.
Choice B Reason: This is incorrect because encouraging the client to allow more time for the medication to work can imply that the nurse does not believe or validate the client's report of pain. It also can delay effective pain relief and increase suffering.
Choice C Reason: This is correct because reviewing the medical record for additional pain medication prescriptions can help identify alternative or adjunctive options for pain management, such as breakthrough doses, rescue doses, or non-opioid analgesics.
Choice D Reason: This is incorrect because administering an additional dose of morphine sulfate 0.2 mg intravenously can cause overdose, respiratory depression, or addiction. The nurse should follow the prescribed dosage, route, and interval of administration and monitor for adverse effects.
Correct Answer is D
Explanation
Choice A: "I'm sorry, but your child's medical information is none of your business." is not a good response because it is rude and disrespectful. The nurse should maintain professionalism and empathy when dealing with parents.
Choice B: "I can give you those results as soon as I get them back from the lab." is not a good response because it violates confidentiality and privacy. The nurse should not share any medical information with anyone without the client's consent.
Choice C: "The healthcare provider will share this information with you." is not a good response because it implies that the parents have a right to know their child's medical information. The nurse should not make promises or assumptions that may not be true.
Choice D: "I can only give medical information to your child because they are legally an adult." is a good response because it explains the legal status of an emancipated minor and respects their autonomy. The nurse should inform the parents that their child has the right to make their own decisions regarding their health care.
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