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?
Decreased peripheral pulses
Heart rate 108/min
Respiratory rate 10 breathes/min
Dilated pupils
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Improved sexual function:
While ACE inhibitors like lisinopril may have a beneficial impact on overall health, improved sexual function is not a direct therapeutic effect of this medication. In fact, ACE inhibitors can sometimes cause side effects like sexual dysfunction in some individuals. Therefore, improved sexual function is not considered a therapeutic outcome for lisinopril.
B) Decreased blood pressure:
Lisinopril is an ACE (angiotensin-converting enzyme) inhibitor that works by blocking the conversion of angiotensin I to angiotensin II, which results in vasodilation and lowered blood pressure. Therefore, a decreased blood pressure is the expected and desired outcome when a client is on lisinopril. This is the primary therapeutic effect of the medication.
C) Increase of HDL cholesterol:
Lisinopril does not have a direct effect on increasing HDL (high-density lipoprotein) cholesterol. While ACE inhibitors may have some indirect cardiovascular benefits, such as improving endothelial function or reducing risk factors for heart disease, raising HDL cholesterol is not one of their specific effects. This outcome would not indicate a therapeutic effect of lisinopril.
D) Prevention of bipolar manic episodes:
Lisinopril is not used for the treatment or prevention of bipolar disorder or its manic episodes. While certain medications, such as mood stabilizers or antipsychotics, may be used in the management of bipolar disorder, lisinopril is not effective for this purpose. Therefore, preventing bipolar manic episodes is not a therapeutic outcome of lisinopril.
Correct Answer is A
Explanation
A) Trough:
The trough level refers to the lowest serum concentration of a medication in the bloodstream, typically measured just before the next dose is administered. This point is crucial for ensuring that drug levels remain within the therapeutic range and for avoiding toxicity. Monitoring the trough level helps healthcare providers determine whether the medication is being cleared appropriately from the system and whether dosage adjustments are needed.
B) Peak:
The peak level is the highest concentration of the medication in the bloodstream, typically measured shortly after the medication is administered. This is the opposite of the trough level. The peak level is important for assessing the maximum therapeutic effect of the medication but does not reflect the lowest concentration.
C) Half-life:
The half-life of a medication is the time it takes for the serum concentration of the drug to decrease by half. While it provides useful information about how long a drug stays in the body, it is not related to the lowest concentration of the drug. The half-life influences dosing intervals but is not directly tied to the concept of trough levels.
D) Toxic:
Toxic levels refer to the concentration of a medication in the blood that is high enough to cause harmful effects or toxicity. This is the opposite of the trough level, which represents the lowest safe level of the drug in the system. Toxicity occurs when drug levels exceed the therapeutic range, posing a risk to the patient’s health.
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