A nurse is caring for a client who has a temperature of 40°C (104°F). Which of the following interventions should the nurse take?
Encourage the client to ambulate.
Give the client a cold sponge bath.
Administer antipyretics as prescribed.
Provide a cooling fan.
The Correct Answer is C
Choice A rationale:
Encouraging the client to ambulate is not appropriate when the client has a high fever of 40°C (104°F). Ambulation requires physical exertion and can potentially worsen the client's condition, especially when they are already experiencing discomfort due to the fever.
Choice B rationale:
Giving the client a cold sponge bath might seem like a logical approach to reduce fever; however, it is not the most effective and safest method. Cold water can cause vasoconstriction and shivering, potentially increasing the body's metabolic demands and raising the temperature further. Additionally, sudden temperature changes can be uncomfortable and may not provide sustained fever reduction.
Choice C rationale:
Administering antipyretics as prescribed is the correct choice. Antipyretic medications, such as acetaminophen or ibuprofen, work to lower fever by acting on the hypothalamus, the body's temperature-regulating center. By reducing fever, the body's metabolic rate and oxygen consumption are decreased, which can help prevent complications associated with high fever, such as dehydration and discomfort.
Choice D rationale:
Providing a cooling fan can offer some comfort, but it might not be sufficient to effectively lower the client's high fever. Fans primarily work by promoting evaporative cooling, which may not be efficient when the body temperature is significantly elevated. Additionally, relying solely on a cooling fan might delay the necessary intervention of administering antipyretic medication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The client's statement about increasing daily intake of calcium and vitamin D indicates an understanding of the teaching related to kyphosis and osteoporosis. Kyphosis is a condition where there is an abnormal curvature of the spine, leading to a hunched-back appearance, and osteoporosis is a condition characterized by weakened bones. Calcium and vitamin D are essential nutrients for maintaining bone health. Calcium is a mineral that is a major component of bones, and vitamin D helps the body absorb calcium from the diet. Adequate intake of these nutrients is crucial for preventing further bone loss and fractures in individuals with kyphosis and osteoporosis.
Choice B rationale:
The client's statement about scheduling an electrophysiologic study is unrelated to the teaching about kyphosis and osteoporosis. Electrophysiologic studies are used to evaluate the electrical activity of the heart, and they are not directly relevant to the client's bone health or the management of kyphosis and osteoporosis.
Choice C rationale:
The client's statement about wearing a neck brace while sleeping to prevent injury is incorrect and indicates a misunderstanding of the teaching. Kyphosis primarily affects the thoracic (upper/mid-back) spine and is not typically associated with wearing a neck brace. Neck braces are more commonly used for cervical spine issues.
Choice D rationale:
The client's statement about avoiding weight-bearing exercise to minimize trauma is incorrect and demonstrates a misunderstanding of the teaching. Weight-bearing exercise, such as walking and strength training, is important for maintaining bone density and muscle strength, which are critical for individuals with kyphosis and osteoporosis. Avoiding weight-bearing exercise could actually lead to further bone loss and weakness.
Correct Answer is B
Explanation
Choice A rationale:
Lying down while practicing pursed-lip breathing is not the correct instruction. Pursed-lip breathing is usually performed in a sitting or standing position. Lying down can restrict lung expansion and may not effectively support the purpose of this breathing technique, which is to improve airway pressure and reduce air trapping.
Choice B rationale:
"Exhale slowly through your mouth" is the correct instruction for pursed-lip breathing. This technique involves inhaling through the nose for a count of two and exhaling slowly and steadily through pursed lips for a count of four. The goal is to promote better exhalation, prevent airway collapse, and improve oxygen exchange. The rationale behind this choice is grounded in the mechanics of pursed-lip breathing, which helps create backpressure in the airways, maintaining them open and aiding in proper exhalation.
Choice C rationale:
Inhaling through pursed lips contradicts the proper sequence of pursed-lip breathing. The technique involves inhaling through the nose and exhaling through pursed lips. Inhaling through pursed lips would not provide the intended benefits of the technique.
Choice D rationale:
"Puff your cheeks when exhaling" is not the correct instruction. Puffing the cheeks during exhalation does not contribute to the effectiveness of pursed-lip breathing. This action could potentially impede proper exhalation and defeat the purpose of the technique, which is to control airflow and improve breathing efficiency.
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