To objectively confirm the presence of fever, before taking the client's temperature, which action should the nurse take?

Ask the client to describe any other related symptoms.

Place the dorsum of the hand on the client's forehead.

Use both hands to hold and palpate the client's hands.

Lightly pinch a fold of skin over the client's sternum.

Answer and Explanation

The Correct Answer is B

Answer: B. Place the dorsum of the hand on the client's forehead.

Rationale:

A) Ask the client to describe any other related symptoms.
While asking the client about symptoms related to fever, such as chills or sweating, can provide useful subjective information, it is not a reliable or objective method to confirm fever. Direct temperature measurement is needed for confirmation.

B) Place the dorsum of the hand on the client's forehead.
Placing the dorsum (back) of the hand on the client’s forehead is a common method to assess skin temperature. While this action provides a quick, non-invasive estimation of whether the client feels warm, it still requires confirmation with an actual temperature measurement using a thermometer for an objective assessment.

C) Use both hands to hold and palpate the client's hands.
Palpating the client's hands may provide information about extremity temperature or circulation, but it is not a reliable method for assessing core body temperature or confirming the presence of fever.

D) Lightly pinch a fold of skin over the client's sternum.
Pinching a fold of skin over the sternum assesses skin turgor, which is a measure of hydration and elasticity, not temperature. It does not provide any indication of whether the client has a fever.

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Correct Answer is B

Explanation

Answer: B. Cardiac enlargement.

Rationale:

A) Cardiac atrophy:
Cardiac atrophy refers to the reduction in the size of the heart muscles and is not typically detected through percussion. It would present differently, likely through imaging or echocardiography, rather than an increase in the area of dullness during percussion.

B) Cardiac enlargement:
Percussion revealing dullness extending from the 5th left intercostal space upward to the 2nd left intercostal space suggests an increase in the size of the heart. This pattern indicates cardiac enlargement, as the heart’s borders have extended beyond their typical boundaries, which are usually confined to the 5th left intercostal space along the midclavicular line.

C) Benign variation:
A benign variation would not typically cause such a significant change in the area of cardiac dullness. This finding is more concerning for pathology, such as cardiomegaly, than a harmless variation.

D) Expected finding:
The normal borders of the heart should not extend upward to the 2nd left intercostal space during percussion. This finding is not within normal limits and suggests an abnormal enlargement of the heart, rather than an expected physiological outcome.

A. Give the client 8 ounces (236.5 mL) of water to drink. B. Evaluate the client for bladder distention. C. Instruct the client to attempt to urinate again. D. Send the sample for laboratory evaluation.

Correct Answer is B

Explanation

A. Give the client 8 ounces (236.5 mL) of water to drink:
While encouraging hydration is important for overall urinary function, providing water to drink may not immediately address the client's current situation of difficulty providing a urine sample. It's essential to first determine if bladder distention is contributing to the client's symptoms.

B. Evaluate the client for bladder distention:
Given the client's symptoms of lower abdominal discomfort and difficulty providing a urine sample despite feeling the urge to urinate, bladder distention should be assessed. Bladder distention could indicate urinary retention, which may require intervention to relieve the discomfort and prevent complications such as urinary tract infection or bladder rupture.

C. Instruct the client to attempt to urinate again:
While encouraging the client to attempt to urinate again may be appropriate, it's essential to first assess for bladder distention to determine if there is an underlying issue contributing to the client's difficulty in providing a urine sample.

D. Send the sample for laboratory evaluation:
Sending the urine sample for laboratory evaluation is important for diagnostic purposes, but in this case, it's more important to address the immediate concern of the client's difficulty in providing an adequate sample. Evaluating for bladder distention would help guide further assessment and management.

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To objectively confirm the presence of fever, before taking the client's temperature, which action should the nurse take?

Rationale:

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Naxlex Comprehensive Predictor Exams

While percussing the borders of the heart, the nurse picks up an area of dullness beginning at the 5th left intercostal space and moving upward to the 2nd left intercostal space at the sternal border. What do these findings indicate?

Correct Answer is B

Explanation

Rationale:

An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample. After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?

Correct Answer is B

Explanation

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