A nurse is assigned a client who has been admitted with a high fever. Which nursing skill should the nurse use at the first contact with the client?

Assessment

Discharge planning

Counseling

No option provided.

Answer and Explanation

The Correct Answer is A

Choice A reason: Assessment is the first step in the nursing process, involving data collection on the client’s fever, vital signs, and symptoms. Fever increases metabolic rate and oxygen demand, potentially causing dehydration or tachycardia. Initial assessment identifies underlying causes (e.g., infection) and guides interventions, ensuring timely treatment to stabilize the client’s physiological status.

Choice B reason: Discharge planning is premature at first contact, as it occurs after assessing and stabilizing the client. Fever may indicate infection, requiring immediate evaluation of vital signs and symptoms to determine etiology. Planning discharge without understanding the client’s condition risks neglecting critical interventions, as fever can escalate systemic inflammatory responses if untreated.

Choice C reason: Counseling addresses emotional or educational needs but is inappropriate at first contact with a high fever. Fever, often from infection, activates inflammatory cytokines, increasing body temperature and heart rate. Assessment of physiological status takes precedence to identify causes and initiate treatment, ensuring patient safety before addressing psychological or educational needs.

Choice D reason: No fourth option was provided, but any non-assessment action would be less urgent. Fever signals a physiological disturbance, like infection, increasing metabolic demand and risking complications like dehydration. Initial assessment of vital signs, history, and symptoms is critical to identify the cause and guide interventions, ensuring effective management of the client’s condition.

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Correct Answer is B

Explanation

Choice A reason: Visual acuity measures the clarity of vision, typically tested using a Snellen chart to assess retinal and optic nerve function. Testing cardinal fields of vision evaluates eye muscle coordination, not visual sharpness. This assessment involves cranial nerves III, IV, and VI, not the retina’s ability to resolve fine details, making it irrelevant here.

Choice B reason: Extraocular movements are assessed by testing the cardinal fields of vision, evaluating the coordinated movement of eyes in six directions. This tests cranial nerves III (oculomotor), IV (trochlear), and VI (abducens), which control eye muscles. Misalignment or uncoordinated movement may indicate neurological or muscular issues, making this the correct characteristic being assessed.

Choice C reason: Peripheral vision is tested using confrontation tests, assessing the visual field’s outer edges, mediated by retinal rod cells. Cardinal fields of vision testing focuses on eye muscle coordination, not the extent of the visual field. This assessment does not evaluate peripheral retinal function, making peripheral vision an incorrect choice for this procedure.

Choice D reason: Existence of cataracts is assessed via lens opacity examination, often using an ophthalmoscope. Cardinal fields of vision testing evaluates eye movement coordination, not lens clarity. Cataracts impair light transmission to the retina, but this test targets extraocular muscle function and cranial nerve integrity, making cataract assessment irrelevant to this procedure.

A. Hypertension. B. A dysrhythmia. C. Tachycardia. D. Bradycardia.

Correct Answer is B

Explanation

Choice A reason: Hypertension is defined by elevated blood pressure, not an irregular heart rate. An irregular pattern at 72 bpm suggests a rhythm abnormality, not a pressure issue. Hypertension affects vascular resistance, not cardiac rhythm directly, making this incorrect for the observed finding, per cardiovascular physiology.

Choice B reason: A dysrhythmia is indicated by an irregular heart rate pattern at 72 bpm, as it reflects abnormal electrical conduction, such as atrial fibrillation or premature beats. Notifying the provider is appropriate, as dysrhythmias may impair cardiac output or indicate underlying pathology, requiring prompt evaluation, per cardiac monitoring protocols.

Choice C reason: Tachycardia is a heart rate above 100 bpm, not applicable to 72 bpm. The irregularity, not speed, is the concern. Tachycardia involves rapid but often regular rhythms, whereas this finding suggests a dysrhythmia, making this choice incorrect for the described clinical presentation, per cardiac assessment.

Choice D reason: Bradycardia is a heart rate below 60 bpm, not matching 72 bpm. The irregular pattern points to a dysrhythmia, not a slow rate. Bradycardia affects heart rate frequency, not rhythm irregularity, making this irrelevant to the finding, which requires rhythm-focused intervention, per cardiac physiology.

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A nurse is assigned a client who has been admitted with a high fever. Which nursing skill should the nurse use at the first contact with the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses a client’s eyes by testing the cardinal fields of vision for coordination and alignment. Which eye characteristic is being assessed by this process?

Correct Answer is B

Explanation

Upon auscultation of a client's heart rate, the nurse notes the rate to have an irregular pattern of 72 bpm. The nurse notifies the health care provider because the client is exhibiting signs of:

Correct Answer is B

Explanation

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