A nurse is caring for a client who has an oral temperature of 39.5°C (103.1°F). Which of the following actions should the nurse take?

Remove excess clothing from the client.

Restrict the client's fluid intake.

Place a warming blanket over the client.

increase the temperature in the client's room.

Answer and Explanation

The Correct Answer is A

A: This helps reduce body temperature by increasing heat loss through evaporation and radiation. Removing layers allows the body’s natural cooling mechanisms to function more effectively.
B: This would be inappropriate because adequate hydration is crucial for a febrile patient to help regulate body temperature and prevent dehydration.
C: This would be counterproductive as it would add heat to the body instead of helping to lower the body temperature.
D: Increasing the room temperature would worsen the situation by making the environment warmer, which would hinder the body's ability to cool down naturally.

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Correct Answer is A

Explanation

A: To accurately determine a pulse deficit, one nurse must listen to the apical pulse while another nurse palpates the radial pulse simultaneously to compare both pulse rates, necessitating a second person.
B: Counting the apical pulse is a part of the process but would follow after ensuring another nurse is available to check the radial pulse at the same time.

C: This action relates to checking a pulse rate generally but does not specify the need for simultaneous comparison with the apical pulse.
D: Calculation of the difference is the final step after both pulses have been counted simultaneously.

A. It is common for intestinal peristalsis to slow down as a person ages, causing problems with constipation. B. Aging patients always have difficulty having a bowel movement while hospitalized C. Elderly patients almost always abuse laxatives, which creates problems with constipation. D. In elderly patients, the rectal sphincter has lost elasticity, which decreases the sensation of urgency.

Correct Answer is A

Explanation

A: Due to age-related reductions in gastrointestinal muscle efficiency, which slows the digestive process and can lead to increased water absorption from stool.
B: Overstates the issue, not all elderly patients experience difficulties, and it does not account for individual variability or other influencing factors like diet and medication.
C: Misrepresents the frequency and reasons for laxative use among the elderly, not all of whom misuse these medications.
D: While changes in rectal sphincter elasticity can affect some elderly individuals, it is less commonly a direct cause of constipation compared to decreased peristalsis.

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A nurse is caring for a client who has an oral temperature of 39.5°C (103.1°F). Which of the following actions should the nurse take?

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