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 D

Explanation

A) Observe for jugular vein distention while the client is flat in bed: While jugular vein distention can indicate fluid overload or heart failure, it is not a direct assessment of orthopnea, which is the difficulty breathing while lying flat.

B) Measure the blood pressure when the client is lying and standing: This action assesses for orthostatic hypotension, which is a drop in blood pressure upon standing. While orthostatic hypotension can contribute to symptoms of dizziness or fainting upon assuming an upright position, it does not directly assess orthopnea.

C) Auscultate breath sounds while the client is supine: Auscultating breath sounds while the client is supine can provide information about lung function and the presence of abnormal breath sounds, but it does not specifically address orthopnea.

D) Ask the client how many pillows are used to sleep on at night: Orthopnea is a condition in which individuals have difficulty breathing while lying flat and may need to sleep with multiple pillows or in a more upright position to alleviate symptoms. Therefore, asking the client about the number of pillows used for sleep can provide valuable information about the presence and severity of orthopnea.

A. Stand directly in front of the client and ask about any hearing loss B. Perform a mental status exam to assess the client's thought processes. C. Begin to orient the client to her surroundings in the hospital room D. Obtain a tuning fork to complete Rinne and Weber tuning fork tests.

Correct Answer is A

Explanation

A) Stand directly in front of the client and ask about any hearing loss:
The client's behavior of ignoring questions and speaking loudly to her son may suggest a hearing impairment. By standing directly in front of the client and asking about any hearing loss, the nurse can assess whether hearing impairment might be contributing to the communication difficulties. This action addresses a potential physiological cause of the observed behavior and allows the nurse to gather essential information to adapt communication strategies effectively.

B) Perform a mental status exam to assess the client's thought processes:
While assessing the client's mental status is important, the observed behavior may be more indicative of a communication issue related to hearing loss rather than a cognitive impairment. Therefore, assessing hearing status would be more appropriate as the initial action.

C) Begin to orient the client to her surroundings in the hospital room:
Orienting the client to her surroundings is important for promoting comfort and reducing confusion, but it may not directly address the observed communication difficulties. Assessing for hearing loss should be prioritized to determine if it contributes to the client's behavior.

D) Obtain a tuning fork to complete Rinne and Weber tuning fork tests:
Conducting Rinne and Weber tuning fork tests may be indicated to assess hearing acuity and differentiate between conductive and sensorineural hearing loss. However, obtaining a tuning fork and performing these tests should occur after gathering initial information about the client's hearing status through direct questioning. Therefore, assessing for hearing loss should be the first action taken by the nurse.

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

Rationale:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During the admission assessment, a client admitted with chest pain reports having no breathing problems and no trouble sleeping at night. To obtain further data regarding possible orthopnea, which action should the nurse take?

Correct Answer is D

Explanation

While interviewing a newly admitted older female client, the nurse observes that the client ignores questions asked by the nurse, and speaks loudly to her son who brought her to the hospital. Which action should the nurse implement first?

Correct Answer is A

Explanation

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