A nurse in an emergency department is caring for a child who reports being sexually abused by a family member. Which of the following actions should the nurse take?

Pyrexia, also known as fever, refers to an elevated body temperature that is above the normal range. The normal body temperature is typically around 37°C (98.6°F), and a temperature of 38.4°C (101.1°F) indicates a fever.

Alternative Choices:

1. "tachycardia" due to "heart rate of 92/min"

• Incorrect. Tachycardia refers to an abnormally high heart rate, usually above 100 beats per minute (bpm) in adults. A heart rate of 92/min is within normal limits and does not qualify as tachycardia.

2. "hypertension" due to "blood pressure of 130/78 mm Hg"

• Incorrect. Hypertension is defined as having a blood pressure reading consistently above 140/90 mm Hg. The reading of 130/78 mm Hg falls into the elevated category but does not reach the threshold for hypertension.

3. "respiratory distress" due to "respiratory rate of 18/min"

• Incorrect. A respiratory rate of 18 breaths per minute is considered normal for adults, so this finding does not indicate respiratory distress.

4. "obesity" due to "current BMI of 29.9"

• Partially correct. A BMI of 29.9 places the client in the "overweight" category, just below the threshold for obesity (BMI of 30 or higher). However, the presence of pyrexia is the more immediate clinical concern based on the provided vital signs.

Jaw pain in a client taking alendronate, a bisphosphonate, for postmenopausal osteoporosis may be a sign of a rare but serious side effect called osteonecrosis of the jaw (ONJ). Therefore, the nurse should respond by: Report the client's jaw pain to the healthcare provider.

Jaw pain can be an indication of ONJ, a condition characterized by the death of jawbone tissue. It is important to notify the healthcare provider so that further evaluation and appropriate management can be initiated. The healthcare provider will determine the best course of action, which may include referral to a specialist for further assessment and treatment.

Determining how the client is administering the medication is not the immediate concern in this situation. While it is important to ensure that the client is following proper administration instructions for alendronate, addressing the jaw pain takes precedence. Advising the client to gargle with warm salt water twice daily may not be sufficient or appropriate for managing jaw pain related to alendronate use. The client needs a comprehensive assessment by the healthcare provider to determine the cause of the jaw pain and provide appropriate interventions.

Confirming that jaw pain is a common symptom of osteoporosis is not accurate. While osteoporosis can lead to bone pain, jaw pain specifically associated with bisphosphonate use is more likely to be related to ONJ and requires further evaluation and management.