A nurse is assessing a client who has an oral temperature of 39 C (102.27 F). Which of the following findings should the nurse expect?

A) Decreased peripheral pulses:
Increased body temperature typically causes vasodilation rather than vasoconstriction, leading to improved blood flow rather than decreased. As a result, peripheral pulses are more likely to be normal or even increased in response to fever. Decreased peripheral pulses would be more indicative of conditions like shock or hypoperfusion, not fever.

B) Heart rate 108/min:
Fever causes an increase in metabolic demand, which often results in a compensatory increase in heart rate (tachycardia). This phenomenon, known as "fever tachycardia," occurs as the body attempts to circulate blood more rapidly to meet the increased oxygen and nutrient demands caused by elevated body temperature. A heart rate of 108 beats per minute is a normal response to fever, particularly when the temperature reaches 39°C (102.27°F).
C) Respiratory rate 10 breaths/min:
A respiratory rate of 10 breaths per minute is considered bradypnea (abnormally slow breathing), which is typically not associated with fever. Fever usually leads to an increase in respiratory rate (tachypnea) as the body attempts to cool itself through increased evaporation of sweat and breathing. A respiratory rate of 10 breaths/min is more likely to be seen in conditions like drug overdose, head injury, or respiratory depression, rather than fever.
D) Dilated pupils:
Dilated pupils (mydriasis) are typically associated with sympathetic nervous system activation, which can be caused by certain drugs, trauma, or neurological conditions. Fever, however, generally causes only mild changes in pupil size and is more likely to lead to constricted pupils (miosis) in response to certain stress hormones. Dilated pupils are not a typical finding with fever.

A) Increased blood pressure:
Fluid overload results in an increased volume of fluid in the vascular system, leading to higher blood pressure. The excess volume places additional strain on the heart and blood vessels, causing an elevation in systolic and diastolic pressure. The nurse should expect to find elevated blood pressure in a client experiencing fluid overload due to the increased blood volume.

B) Increased hematocrit:
Hematocrit is the proportion of red blood cells in the blood, and it tends to decrease, not increase, during fluid overload. This is because the excess fluid in the bloodstream dilutes the blood, lowering the hematocrit level. Therefore, an increase in hematocrit would not be expected in fluid overload.

C) Increased respiratory rate:
Fluid overload, particularly when it affects the lungs (as seen in conditions like congestive heart failure), can cause respiratory distress. The accumulation of fluid in the lungs impairs gas exchange, leading to hypoxia and the body compensating by increasing the respiratory rate. This response helps increase oxygenation and expel carbon dioxide, so the nurse should expect to see an increased respiratory rate.

D) Increased heart rate:
An elevated heart rate, or tachycardia, is a compensatory response to fluid overload. The heart tries to pump the excess fluid through the circulatory system, which increases the heart's workload. As a result, the heart rate increases in an attempt to maintain adequate cardiac output despite the increased blood volume.

E) Increased temperature:
An elevated body temperature is not typically associated with fluid overload. In fact, fluid overload is more likely to present with normal or slightly lower body temperature, especially if there is no infection or inflammatory process present. If there is an increase in temperature, the nurse should consider other possible causes, such as infection or inflammatory conditions.