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 D
Explanation
Choice A: Remind the UAP to dry between the client’s toes completely is not the best action because it does not address the risk of spillage and wetness on the bed. Drying between the toes is important to prevent fungal infections, but it can be done after removing the basin.
Choice B: Advise the UAP that this procedure is damaging to the skin is not the best action because it is not accurate and may cause confusion. Soaking the foot in warm water is not harmful to the skin, unless it is too hot or too long.
Choice C: Add skin cream to the basin of water while the foot is soaking is not the best action because it does not solve the problem and may waste the cream. Skin cream should be applied after drying the foot, not mixed with water.
Choice D: Remove the basin of water from the client’s bed immediately is the best action because it prevents potential hazards such as soaking, infection, or electric shock. The nurse should ensure that the bed is dry and clean before continuing with the bath.
Correct Answer is ["B"]
Explanation
Choice A Reason: This is incorrect because nociceptive pain is caused by stimulation of nociceptors, which are sensory receptors that respond to tissue damage or inflammation. Nociceptive pain is usually localized and throbbing or aching.
Choice B Reason: This is correct because neuropathic pain is caused by damage or dysfunction of the nervous system. Neuropathic pain is usually diffuse and burning or shooting.
Choice C Reason: This is incorrect because acute pain is defined by its duration rather than its cause or quality. Acute pain lasts less than six months and usually has an identifiable cause and predictable course.
Choice D Reason: This is incorrect because visceral pain is caused by stimulation of nociceptors in the internal organs. Visceral pain is usually deep and cramping or squeezing.
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