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 ["A","B","C","D"]
Explanation
Choice A Reason: This is correct because hospice provides comfort, dignity, and emotional support to clients with terminal illnesses and their families. Hospice focuses on palliative care rather than curative treatment.
Choice B Reason: This is correct because hospice can be provided within comforts of home or in other settings such as nursing homes or hospice facilities. Hospice allows clients to die in their preferred environment.
Choice C Reason: This is correct because hospice services can be initiated prior to discharge from the hospital or at any time during the course of the illness. Hospice requires a physician's order and a prognosis of six months or less to live.
Choice D Reason: This is correct because family members can be involved in the plan of care and receive education, counseling, and bereavement support from hospice staff. Hospice promotes family-centered care and respects cultural and spiritual preferences.
Choice E Reason: This is incorrect because a living will remains valid when receiving hospice care. A living will is a legal document that expresses the client's wishes regarding life-sustaining treatments in case of incapacity.
Correct Answer is C
Explanation
Choice A: Limitations to range of motion are not directly related to the application of a heating pad. A heating pad may help reduce pain and stiffness, but it does not affect the range of motion itself.
Choice B: Muscle strength and tone are also not directly related to the application of a heating pad. A heating pad may relax tense muscles, but it does not affect the strength or tone of the muscles.
Choice C: Degree of neurosensory impairment is the most important assessment for the nurse to perform prior to the application of a heating pad. A heating pad can cause burns or tissue damage if the patient has impaired sensation and cannot feel the heat or pain. The nurse should check the patient's ability to perceive temperature, pressure, and pain before applying a heating pad.
Choice D: Presence of rebound phenomenon is not relevant to the application of a heating pad. Rebound phenomenon refers to the worsening of symptoms after discontinuing a medication or treatment. A heating pad does not cause rebound phenomenon.
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