An 84-year-old client has been admitted to the emergency department from an extended care facility. The facility staff suspect pneumonia and it is noted that the client has a productive cough, shortness of breath, and abnormal breath sounds. The nurse assesses the client's vital signs and notes an oral temperature of 97.5°F. How should the nurse interpret this assessment finding?
The client's infection is no longer localized and has become systemic.
The client likely has a cardiac health problem, not a respiratory health problem.
The client's signs and symptoms are related to hypothermia rather than infection.
The client's normothermic temperature does not rule out the presence of an infection.
The Correct Answer is D
A. Systemic infection can cause fever, but older adults often present with atypical signs, including a lack of fever, rather than the classic response.
B. The presence of a productive cough, abnormal breath sounds, and shortness of breath suggests a respiratory infection rather than a cardiac issue.
C. While older adults may be more susceptible to hypothermia, the client’s symptoms align with infection rather than hypothermia.
D. "The client's normothermic temperature does not rule out the presence of an infection" is correct because older adults may have a blunted febrile response to infection due to age-related changes in thermoregulation. An absence of fever does not exclude infection in elderly patients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Systemic infection can cause fever, but older adults often present with atypical signs, including a lack of fever, rather than the classic response.
B. The presence of a productive cough, abnormal breath sounds, and shortness of breath suggests a respiratory infection rather than a cardiac issue.
C. While older adults may be more susceptible to hypothermia, the client’s symptoms align with infection rather than hypothermia.
D. "The client's normothermic temperature does not rule out the presence of an infection" is correct because older adults may have a blunted febrile response to infection due to age-related changes in thermoregulation. An absence of fever does not exclude infection in elderly patients.
Correct Answer is D
Explanation
A. Consulting clinical resources is helpful but should be done after reviewing the client’s specific information.
B. Performing a mini overview of body systems occurs during the assessment, not before meeting the client.
C. Gathering materials is important but comes after understanding the client’s history.
D. Reviewing the client’s medical record is correct because it helps the nurse gather baseline information, understand past medical history, and prepare for the assessment effectively.
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