A nurse is caring for a client who has an oral temperature of 39.5°C (103.1°F). Which of the following actions should the nurse take?

Remove excess clothing from the client.

Restrict the client's fluid intake.

Place a warming blanket over the client.

increase the temperature in the client's room.

Answer and Explanation

The Correct Answer is A

A: This helps reduce body temperature by increasing heat loss through evaporation and radiation. Removing layers allows the body’s natural cooling mechanisms to function more effectively.
B: This would be inappropriate because adequate hydration is crucial for a febrile patient to help regulate body temperature and prevent dehydration.
C: This would be counterproductive as it would add heat to the body instead of helping to lower the body temperature.
D: Increasing the room temperature would worsen the situation by making the environment warmer, which would hinder the body's ability to cool down naturally.

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Correct Answer is B

Explanation

A: The daughter's anxiety is secondary information and not directly related to the patient's health status.
B: The patient's self-reported medical history is primary data as it comes directly from the patient and provides essential information for the assessment.
C: The spouse's report of the patient's difficulty sleeping is secondary information and not directly observed or reported by the patient.
D: The caregiver's complaint is secondary information and does not provide direct insight into the patient's health status.

A. Anisocoria of the patient's pupils. B. Patient's accommodation response. C. Direct pupil response of the patient. D. Patient's consensual reflex.

Correct Answer is B

Explanation

A: Anisocoria refers to a condition where the pupils are of unequal sizes, which is not related to focusing ability.

B: Accommodation response involves the ability of the eye to change focus from distant to near objects, demonstrating the flexibility of the lens which is exactly what the instruction aims to test.
C: Direct pupil response relates to pupil constriction in response to light, not changes in focal distance.
D: Consensual reflex also refers to the reaction of both pupils to light and would not be assessed through changes in focal distance.

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A nurse is caring for a client who has an oral temperature of 39.5°C (103.1°F). Which of the following actions should the nurse take?

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