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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A) Potassium level 3 mEq/L:
A potassium level of 3 mEq/L is below the normal range (which is typically 3.5-5.0 mEq/L) and represents hypokalemia. Potassium is crucial for normal muscle and nerve function, including cardiac function. Low potassium levels can lead to dangerous arrhythmias, muscle weakness, and cardiac arrest if not addressed promptly. This is the priority value because hypokalemia can be life-threatening and requires immediate attention from the healthcare provider to correct the imbalance.

B) BUN 9.5 mg/dl:
A BUN (blood urea nitrogen) level of 9.5 mg/dL is within the normal reference range for most adults (typically 7-20 mg/dL). While an abnormal BUN level could indicate kidney dysfunction or dehydration, this value is not immediately concerning and does not represent a critical finding that requires urgent attention.

C) Creatinine 0.4 mg/dl:
A creatinine level of 0.4 mg/dL is below the normal range (usually around 0.6-1.2 mg/dL), which might indicate low muscle mass or a transient decrease in kidney function. However, a low creatinine level is generally not as urgent or concerning as an elevated level, and it does not typically require immediate intervention

D) Sodium 135 mEq/L:
A sodium level of 135 mEq/L is slightly below the normal range (135-145 mEq/L), indicating mild hyponatremia. Although this can be concerning if the drop is acute or symptomatic (e.g., causing confusion, seizures, or lethargy), a mild decrease in sodium is not immediately life-threatening unless it worsens rapidly.

A. Dehydration B. Rigid abdomen C. Hypothermia D. Decreased bowel sounds

Correct Answer is A

Explanation

A) Dehydration:
Diarrhea, especially when prolonged for several days, leads to significant fluid and electrolyte loss, which can result in dehydration. Common signs of dehydration include dry mucous membranes, decreased skin turgor, low urine output, hypotension, and increased heart rate. Dehydration is one of the most expected findings in a patient with prolonged diarrhea due to the loss of water and electrolytes from the body.
B) Rigid abdomen:
A rigid abdomen could indicate peritonitis or a serious abdominal condition such as bowel perforation, which is a medical emergency. This would not be expected in a patient with uncomplicated diarrhea. Rigid abdominal muscles are typically associated with acute abdominal emergencies rather than simple diarrhea.
C) Hypothermia:
Hypothermia is generally not associated with diarrhea. Diarrhea is more likely to cause fever or a normal body temperature due to the body's inflammatory response to infection or irritation. Hypothermia typically occurs in cases of prolonged exposure to cold or in critically ill patients, but it is not a typical response to diarrhea alone.
D) Decreased bowel sounds:
While decreased or absent bowel sounds can be seen in bowel obstruction or paralytic ileus, it is not typically a finding associated with diarrhea. In fact, in the early stages of diarrhea, increased bowel sounds (hyperactive bowel sounds) are often noted due to the rapid peristalsis and gastrointestinal irritation.

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