To objectively confirm the presence of fever, before taking the client's temperature, which action should the nurse take?

Ask the client to describe any other related symptoms.

Place the dorsum of the hand on the client's forehead.

Use both hands to hold and palpate the client's hands.

Lightly pinch a fold of skin over the client's sternum.

Answer and Explanation

The Correct Answer is B

Answer: B. Place the dorsum of the hand on the client's forehead.

Rationale:

A) Ask the client to describe any other related symptoms.
While asking the client about symptoms related to fever, such as chills or sweating, can provide useful subjective information, it is not a reliable or objective method to confirm fever. Direct temperature measurement is needed for confirmation.

B) Place the dorsum of the hand on the client's forehead.
Placing the dorsum (back) of the hand on the client’s forehead is a common method to assess skin temperature. While this action provides a quick, non-invasive estimation of whether the client feels warm, it still requires confirmation with an actual temperature measurement using a thermometer for an objective assessment.

C) Use both hands to hold and palpate the client's hands.
Palpating the client's hands may provide information about extremity temperature or circulation, but it is not a reliable method for assessing core body temperature or confirming the presence of fever.

D) Lightly pinch a fold of skin over the client's sternum.
Pinching a fold of skin over the sternum assesses skin turgor, which is a measure of hydration and elasticity, not temperature. It does not provide any indication of whether the client has a fever.

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Correct Answer is B

Explanation

The symptoms described, including gnawing epigastric pain that worsens when hungry and improves after eating, are classic manifestations of peptic ulcer disease (PUD). Peptic ulcers are erosions in the mucosal lining of the stomach or duodenum, often caused by Helicobacter pylori infection or nonsteroidal anti-inflammatory drugs (NSAIDs). The pain typically occurs when the stomach is empty and is relieved by food intake due to the buffering effect of food on gastric acid. This pattern of pain is known as "hunger pain" or "meal-related pain" and is characteristic of PUD.

A. Esophagitis:
Esophagitis refers to inflammation of the esophagus, often due to reflux of gastric contents into the esophagus. Symptoms may include heartburn, difficulty swallowing, and chest pain, but the pain is typically not related to hunger and food intake as described in the scenario.

C. Gastroesophageal reflux (GERD):
GERD involves the reflux of gastric contents into the esophagus, leading to symptoms such as heartburn, regurgitation, and chest pain. While GERD can cause epigastric discomfort, the described pattern of pain worsening with hunger and improving after eating is more indicative of PUD.

D. Chronic pancreatitis:
Chronic pancreatitis is characterized by inflammation and irreversible damage to the pancreas, leading to persistent abdominal pain, often radiating to the back. While epigastric pain is a feature of chronic pancreatitis, the relief of pain after eating is not typically seen, making it less likely in this scenario.

A. Palpate dorsal surface of feet for warmth. B. Test feet for a positive Babinski reflex. C. Measure skin elasticity around the ankles. D. Assess volume of the pedal pulses. E. Observe color of the feet and toes.

Correct Answer is ["A","D","E"]

Explanation

A) Palpate dorsal surface of feet for warmth:
Assessing the temperature of the dorsal surface of the feet helps determine peripheral circulation and can indicate whether the feet are indeed cold. Cold feet may suggest poor peripheral perfusion or circulation issues, which require further assessment.

B) Test feet for a positive Babinski reflex:
The Babinski reflex is typically tested to assess upper motor neuron dysfunction and is not directly relevant to evaluating the complaint of cold feet.

C) Measure skin elasticity around the ankles:
Measuring skin elasticity around the ankles may be relevant for assessing skin turgor and hydration status but is not specifically related to evaluating the client's complaint of cold feet.

D) Assess volume of the pedal pulses:
Assessing the volume of pedal pulses provides information about peripheral perfusion and circulation. Diminished or absent pedal pulses may indicate peripheral vascular disease or other circulatory issues contributing to cold feet. It's essential to evaluate the strength and symmetry of pedal pulses to determine peripheral vascular status.

E) Observe color of the feet and toes:
While observing the color of the feet and toes is important for assessing circulation and perfusion, it is not specific to evaluating the client's complaint of cold feet. However, color changes, such as pallor or cyanosis, may provide additional information about peripheral circulation and require further assessment.

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To objectively confirm the presence of fever, before taking the client's temperature, which action should the nurse take?

Rationale:

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Naxlex Comprehensive Predictor Exams

An adult client presents with gnawing epigastric pain. The pain is worse when the client is hungry and abates after eating something. Which problem do these symptoms suggest?

Correct Answer is B

Explanation

An older male client reports to the nurse that his feet are cold. Before covering the client's feet, which assessment(s) should the nurse complete? Select all that apply.

Correct Answer is ["A","D","E"]

Explanation

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