A nurse is assessing a client who has an oral temperature of 39° C (102.2° F). Which of the following findings should the nurse expect?
Decreased peripheral pulses
Dilated pupils
Respiratory rate 10/min
Heart rate 108/min
The Correct Answer is D
A. Decreased peripheral pulses. Fever leads to vasodilation and increased cardiac output, which generally enhances peripheral blood flow. As a result, peripheral pulses are more likely to be strong and bounding rather than decreased.
B. Dilated pupils. Pupil dilation is associated with sympathetic nervous system activation, often due to stress, fear, or certain medications. Fever alone does not typically cause pupil dilation, making this an unlikely expected finding.
C. Respiratory rate 10/min. Fever usually increases metabolic demand, leading to a higher respiratory rate (tachypnea) rather than a lower one. A respiratory rate of 10 breaths per minute would be considered bradypnea, which is not a typical response to fever.
D. Heart rate 108/min. Fever stimulates the sympathetic nervous system, increasing heart rate (tachycardia) to meet the body’s higher metabolic and oxygen demands. A heart rate of 108/min is expected in response to a fever of 39°C (102.2°F).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Demographic data. An electronic health record (EHR) includes demographic information such as the client’s name, date of birth, contact details, and medical history. This data helps healthcare providers personalize care and ensure accurate record-keeping.
B. Billing payments. While healthcare facilities may have electronic billing systems, financial transactions and payments are not considered a core component of the EHR, which primarily focuses on clinical documentation and patient care.
C. Driver's license. A driver's license may be used for identity verification during registration, but it is not a required component of an EHR. Identifying information is documented separately from clinical records.
D. Facility policies. EHRs store patient-related health information rather than institutional policies. Facility policies are typically maintained in administrative systems or policy manuals, separate from patient medical records.
Correct Answer is D
Explanation
A. Hypoglycemia. Acute pain does not directly cause hypoglycemia. While stress responses can influence blood sugar levels, pain typically triggers the release of catecholamines, which increase glucose levels rather than decrease them.
B. Bradycardia. Pain activates the sympathetic nervous system, leading to an increase in heart rate (tachycardia) rather than a decrease (bradycardia). Bradycardia is more commonly associated with parasympathetic activation or certain medications.
C. Decreased respiratory rate. Pain often causes an increase in respiratory rate (tachypnea) due to heightened sympathetic stimulation. A decreased respiratory rate would be more likely in cases of severe sedation or opioid overdose, not in response to acute pain.
D. Hypertension. Acute pain stimulates the release of stress hormones such as epinephrine and norepinephrine, leading to vasoconstriction and increased blood pressure. This is a common physiological response to pain as the body prepares to react to the perceived threat.
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