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 C

Explanation

The correct answer is choiceC. “I’ll compare the sensations I feel when I tense my muscles to what I feel when I relax them.”

Choice A rationale:While breathing normally is important during relaxation techniques, progressive muscle relaxation specifically focuses on tensing and relaxing muscle groups to recognize the difference in sensations.

Choice B rationale:Imagining a peaceful setting is more related to guided imagery or visualization techniques, not progressive muscle relaxation.

Choice C rationale:This is correct because progressive muscle relaxation involves tensing and then relaxing muscle groups to help the individual recognize the difference between tension and relaxation.

Choice D rationale:Using a series of stretches is not a part of progressive muscle relaxation; it is more related to stretching exercises or yoga.

A. "Does your family know that you are feeling anxious?". B. "Tell me about where you lived when you were growing up.". C. "Let's talk after I finish caring for my other clients.". D. "Why are you feeling anxious?".

Correct Answer is B

Explanation

Choice A rationale:

Inquiring whether the client's family knows about their anxiety is not directly related to addressing the client's current anxiety. The focus should be on the client's feelings and needs rather than involving the family in this particular instance.

Choice B rationale:

This choice is the most appropriate response. Asking the client to share memories from their past redirects their attention from the current anxiety-provoking situation. Discussing positive memories can help alleviate anxiety and provide comfort to the client.

Choice C rationale:

Suggesting to talk later after caring for other clients dismisses the client's immediate need for support and comfort. It's essential to address the client's anxiety promptly rather than delaying the discussion.

Choice D rationale:

Asking the client why they are feeling anxious might put them on the spot and could potentially escalate their anxiety. Instead of prompting them to explain the cause of their anxiety, the nurse should focus on providing reassurance and distraction.

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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:

Nursing Test Bank

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