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 C

Explanation

A) Looking at the client from the side, observe the size and shape of the chest wall:
This action is more related to inspecting the physical appearance and symmetry of the chest wall but does not assess tactile fremitus.

B) Use the fingertips to compress tissue over the lungs for evidence of a crackling sensation:
This action may be more relevant for assessing subcutaneous emphysema (crepitus) but is not the correct method for assessing tactile fremitus.

C) Place the palm of the hand on the chest wall to feel vibrations while the client speaks:
This is the correct action to assess tactile fremitus. By placing the palm of the hand on various areas of the chest wall while the client repeats a phrase such as "ninety-nine," the nurse can feel for vibrations. Increased tactile fremitus can indicate consolidation, as seen in pneumonia.

D) Use a stethoscope to listen to and compare breath sounds anteriorly and posteriorly:
This action involves auscultation, which is important for assessing breath sounds but does not assess tactile fremitus directly.

A. Closed ended questions. B. Leading questions. C. Detailed questions about a symptom. D. Open ended questioning.

Correct Answer is D

Explanation

A) Closed ended questions:
Closed-ended questions typically elicit short, specific responses and may not provide comprehensive information about the sputum's characteristics.

B) Leading questions:
Leading questions suggest a particular answer and may bias the client's response, preventing the nurse from obtaining an accurate description of the sputum.

C) Detailed questions about a symptom:
While detailed questions can be useful, they may be too specific initially and might not allow the client to freely describe their sputum in their own words.

D) Open ended questioning:
Open-ended questions encourage the client to provide more detailed and descriptive responses, allowing the nurse to gather comprehensive information about the sputum's color, consistency, amount, and other characteristics. This technique is best for obtaining a thorough and accurate description of symptoms.

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

Rationale:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In assessing tactile fremitus in the client with suspected pneumonia, the nurse should perform which action?

Correct Answer is C

Explanation

While completing a health assessment for a client being admitted with bilateral pneumonia, the nurse asks the client to describe the sputum. Which communication technique should the nurse use to obtain this information?

Correct Answer is D

Explanation

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When systematically auscultating a client's anterior breath sounds, the nurse should begin by placing the stethoscope over which location?

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