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: Placing the bedside table at the foot of the bed may not directly reduce the risk of injury for a client with dementia.
B: Assisting the client to the toilet frequently can prevent falls and accidents associated with incontinence, which are common concerns for clients with dementia.
C: Raising the side rails up can potentially increase the risk of injury if the client attempts to climb over them, leading to falls or entrapment.
D: Keeping the television on during the night may not directly address the risk of injury for the client.

A. Circulatory overload B. Extravasation C. Phlebitis D. Infiltration

Correct Answer is C

Explanation

A. Circulatory overload is characterized by symptoms such as dyspnea, crackles, and increased blood pressure, rather than localized redness and warmth.
B. Extravasation refers to the leakage of IV fluid into surrounding tissue, causing swelling and pain.
C. Redness and warmth around the peripheral catheter insertion site are indicative of phlebitis, which is inflammation of the vein. It's essential to document this finding accurately to monitor for worsening or complications.
D. Infiltration occurs when IV fluid leaks into the surrounding tissue, but it typically presents with swelling, pallor, and coolness at the site rather than redness and warmth.

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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

A nurse in a long-term care facility is admitting a client who has dementia. Which of the following actions should the nurse take to reduce the risk for client injury?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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