An 84-year-old client has been admitted to the emergency department from an extended care facility. The facility staff suspect pneumonia and it is noted that the client has a productive cough, shortness of breath, and abnormal breath sounds. The nurse assesses the client's vital signs and notes an oral temperature of 97.5°F. How should the nurse interpret this assessment finding?
The client's infection is no longer localized and has become systemic.
The client likely has a cardiac health problem, not a respiratory health problem.
The client's signs and symptoms are related to hypothermia rather than infection.
The client's normothermic temperature does not rule out the presence of an infection.
The Correct Answer is D
A. Systemic infection can cause fever, but older adults often present with atypical signs, including a lack of fever, rather than the classic response.
B. The presence of a productive cough, abnormal breath sounds, and shortness of breath suggests a respiratory infection rather than a cardiac issue.
C. While older adults may be more susceptible to hypothermia, the client’s symptoms align with infection rather than hypothermia.
D. "The client's normothermic temperature does not rule out the presence of an infection" is correct because older adults may have a blunted febrile response to infection due to age-related changes in thermoregulation. An absence of fever does not exclude infection in elderly patients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. "Client denies recent constipation, diarrhea, bowel incontinence, or abdominal pain." is correct because it is the most specific and complete documentation of the client’s subjective report. It ensures clarity, accuracy, and thorough assessment.
A. This is incorrect because stating "within normal limits" is vague and does not specify what was assessed.
B. This is incorrect because stating "problems are not present" is too general and does not include specific symptoms the client was asked about.
C. This is incorrect because "denies gastrointestinal signs and symptoms" lacks specificity regarding which symptoms were assessed.
Correct Answer is C
Explanation
A. Wearing gloves before touching the client is not necessary unless the nurse anticipates contact with bodily fluids, non-intact skin, or mucous membranes.
B. Using a separate, disposable blood pressure cuff is an example of transmission-based precautions, not standard precautions, unless the client has an infection requiring contact precautions.
C. Wearing gloves to palpate the tongue and buccal membranes is correct because standard precautions require gloves when there is potential contact with mucous membranes, which can expose the nurse to infectious agents.
D. Wearing a gown, gloves, and mask is unnecessary unless the client has an infection that requires additional precautions beyond standard precautions.
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