A nurse is planning care for a client who has a fever due to an infection. Which of the following interventions should the nurse include in the plan of care?

Encourage fluid intake of 2,500 mL/day.

Maintain the environmental temperature at 16°C to 18°C (60°F to 65°F).

Immerse the client in cold water.

Assist the client to ambulate.

Answer and Explanation

The Correct Answer is A

Choosing the best intervention for a client with fever due to infection:

The most appropriate intervention for a client with fever due to infection depends on various factors, including the severity of the fever, the client's age and overall health, and their individual preferences. Let's analyze each option and explain its rationale:

a. Encourage fluid intake of 2,500 mL/day.

Rationale:

Pros: Fever often leads to increased sweating and fluid loss through respiration. Maintaining adequate hydration is crucial to prevent dehydration, which can worsen discomfort and potentially lead to complications like organ dysfunction. Encouraging a fluid intake of 2,500 mL/day is generally recommended for adults with fever, although individual needs may vary based on factors like body size and activity level.
Cons: While hydration is essential, forcing fluids on a client who experiences nausea or vomiting can be counterproductive. Additionally, some clients with certain medical conditions, like heart failure, may require fluid restriction, making this option inappropriate.

b. Maintain the environmental temperature at 16°C to 18°C (60°F to 65°F).

Rationale:

Cons: Excessively cool environments can trigger shivering, which actually increases body heat production and can worsen the fever. Additionally, maintaining such a low room temperature can be uncomfortable for the client and may increase their risk of chills.

c. Immerse the client in cold water.

Rationale:

Cons: Immersing a client in cold water, like a bath, can be a dangerous and counterproductive intervention. The sudden chill can trigger violent shivering, significantly increasing body heat production and potentially causing shock. Moreover, rapid cooling can be uncomfortable and even risky for people with certain health conditions like heart disease.

d. Assist the client to ambulate.

Rationale:

Cons: While ambulation is generally encouraged for healthy clients, it may not be suitable for everyone with a fever. Depending on the severity of the fever and the client's overall condition, ambulation could be tiring and even unsafe. In some cases, rest may be more appropriate to promote comfort and recovery.

Therefore, the most appropriate intervention for a client with fever due to infection is:

a. Encourage fluid intake of 2,500 mL/day.

Remember:

Individualize care based on the client's specific needs and preferences.
Monitor the client's response to interventions and adjust as needed.
Consult with the healthcare provider for guidance on managing the fever and addressing any underlying infection.

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Correct Answer is A

Explanation

Choice A rationale:

Providing oral replacement solution is the nurse's priority in this situation. Diarrhea can lead to dehydration and electrolyte imbalances due to fluid loss. Oral rehydration solutions contain electrolytes and fluids that can help restore the body's hydration balance. Ensuring the client's adequate fluid intake takes precedence in preventing complications associated with diarrhea.

Choice B rationale:

Obtaining a prescription for antidiarrheal medication is important, but it is not the priority action. The client's dehydration and electrolyte imbalance should be addressed first through oral rehydration before focusing on symptom management.

Choice C rationale:

Offering the client a sitz bath is not the priority action for someone experiencing diarrhea. Sitz baths are typically used for conditions affecting the perineal area, such as hemorrhoids or perineal discomfort. However, in the case of diarrhea, the primary concern is managing fluid and electrolyte balance.

Choice D rationale:

Collecting a specimen of the client's stool is important for diagnostic purposes, but it is not the immediate priority. The client's hydration status and electrolyte balance should be addressed promptly to prevent complications. Stool collection can be considered once the client's hydration has been stabilized.

A. Increased sensitivity to touch. B. Decreased peripheral circulation. C. Decreased airway resistance. D. Increased appetite.

Correct Answer is B

Explanation

Choice A rationale:

Increased sensitivity to touch is not an expected physiological change associated with aging. Older adults often experience decreased sensitivity to touch due to changes in nerve endings and decreased skin elasticity. This can lead to decreased sensation rather than increased sensitivity.

Choice B rationale:

Decreased peripheral circulation is an expected physiological change associated with aging. With age, blood vessels can become less elastic and more narrow, leading to reduced blood flow to the extremities. This can result in cold extremities, delayed wound healing, and increased vulnerability to skin breakdown. Nurses should assess for signs of impaired circulation in older adult clients and provide appropriate interventions to prevent complications.

Choice C rationale:

Decreased airway resistance is not an expected physiological change associated with aging. Older adults often experience increased airway resistance due to changes in lung elasticity and chest wall compliance. This can lead to decreased lung function and a higher risk of respiratory issues such as pneumonia and bronchitis.

Choice D rationale:

Increased appetite is not an expected physiological change associated with aging. In fact, many older adults experience a decrease in appetite due to factors such as changes in metabolism, decreased sense of taste and smell, and underlying health conditions. This reduced appetite can contribute to malnutrition and weight loss in the elderly population.

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A nurse is planning care for a client who has a fever due to an infection. Which of the following interventions should the nurse include in the plan of care?

Choosing the best intervention for a client with fever due to infection:

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