A nurse is caring for a client who is febrile. To reduce the client's fever, the nurse applies a cooling blanket. Which of the following findings indicates the client is having an adverse reaction to the cooling?

Tachycardia

Shivering

Flushing

Restlessness

Answer and Explanation

The Correct Answer is B

A: Tachycardia might occur due to the fever itself but isn't a specific reaction to the cooling method.
B: Shivering is an adverse reaction because it indicates that the body is trying to generate heat to counteract the cooling effect of the blanket, which can increase metabolic demand and is counterproductive.
C: Flushing is typically related to fever or other causes but not directly to the adverse reaction of cooling.
D: Restlessness can be caused by discomfort or the fever itself, not specifically by cooling.

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Correct Answer is B

Explanation

A. Monitoring vital signs every 12 hours is a standard nursing intervention but may not specifically address the needs of a client with immunosuppression.
B. Inspecting the client's mouth every 8 hours can help in early detection of mouth sores or infections, which are common in immunosuppressed individuals.
C. Providing fresh fruit with meals may not be appropriate for a client with immunosuppression, as fresh fruits can harbor pathogens that pose a risk of infection.
D. Rotating healthcare staff caring for the client helps increases the risk of introducing pathogens to the client. This increases the risk of infection in the immunosuppressed client.

A. Swallowing ability B. Changes in appetite C. Prescribed medications D. Daily fluid intake

Correct Answer is A

Explanation

A: Swallowing ability is crucial because ALS often leads to dysphagia, which can cause weight loss due to difficulty eating and the risk of aspiration.
B: Changes in appetite are important but secondary to physical ability to eat safely.

C: While knowing about prescribed medications is necessary, it does not directly address the issue of weight loss as critically as swallowing ability.
D: Fluid intake is important but the priority is assessing the ability to swallow safely, which directly impacts nutritional status.

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A nurse is caring for a client who is febrile. To reduce the client's fever, the nurse applies a cooling blanket. Which of the following findings indicates the client is having an adverse reaction to the cooling?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

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