A 75-year-old client has a baseline oral temperature of 96.8° F (36° C). Two hours later the client’s oral temperature is 100.8° F (38.2° C).
Which action should a nurse take next?

An idiosyncratic drug effect is an unpredictable and uncommon reaction to a drug that is not related to the dose, the pharmacology, or the patient’s allergy or intolerance. It may be caused by genetic factors, metabolic abnormalities, or interactions with other drugs or substances. An example of an idiosyncratic drug effect is paradoxical agitation or excitement after receiving a sedative.

B. A toxic drug effect is a harmful reaction to a drug that is related to the dose or the pharmacology of the drug. It may cause symptoms such as nausea, vomiting, drowsiness, confusion, or respiratory depression. A toxic drug effect is unlikely to cause agitation after receiving a sedative unless there is an overdose or a drug interaction that increases the level of the sedative in the blood.

C. An allergic drug response is an immunological reaction to a drug that is not related to the dose or the pharmacology of the drug. It may cause symptoms such as rash, itching, swelling, fever, or anaphylaxis. An allergic drug response is unlikely to cause agitation after receiving a sedative unless there is a severe anaphylactic reaction that affects the brain or the circulation.

D. An unexpected drug interaction is a modification of the effect of one drug by another drug or substance that is not predictable based on their pharmacology. It may cause an increase or a decrease in the efficacy or toxicity of one or both drugs. An unexpected drug interaction may cause agitation after receiving a sedative if there is a synergistic effect that enhances the central nervous system stimulation of another drug or substance (such as caffeine, cocaine, or amphetamines) or if there is an antagonistic effect that reduces the central nervous system depression of the sedative (such as flumazenil, naloxone, or physostigmine). However, these interactions are usually known and avoidable by checking the patient’s history and medication list.

The nurse should use clarifying points made by the patient that are unclear and listening attentively while speaking slowly and clearly as communication techniques when performing a health history.

These techniques help the nurse to gather accurate and comprehensive information from the patient and to establish rapport and trust.

Choice A is wrong because avoiding silences can make the patient feel rushed or interrupted. Silences can be useful to allow the patient to think or express emotions.

Choice D is wrong because sitting approximately two feet away from the client may be too close and invade the personal space of the client. The nurse should maintain a comfortable distance of about 4 to 5 feet from the client, depending on the cultural norms and preferences of the client.

Choice E is wrong because asking the family member to complete the written form may not reflect the true health history of the client. The nurse should obtain the information directly from the client whenever possible, unless the client is unable or unwilling to provide it.