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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A) Compare the shape of each of the pupils bilaterally with normal room light:
Assessing the shape of the pupils with normal room light is not specifically related to assessing pupillary reaction to accommodation. This action may be more relevant for assessing pupillary symmetry and shape, but it does not directly evaluate accommodation.

B) Determine if dilation of the pupils occurs when the room is darkened:
This action assesses the pupillary response to changes in light (pupillary light reflex), not specifically accommodation. While it is an important assessment, it does not target accommodation specifically.

C) Note the speed of pupil constriction when a penlight is shined into the eye:
This action assesses the pupillary light reflex, which involves the constriction of the pupils in response to light. While it is related to pupillary function, it does not specifically evaluate accommodation.

D) Observe pupil size when focusing on a near object and then a far object:
This action directly assesses the pupillary reaction to accommodation. When focusing on a near object, the pupils should constrict (miosis), and when focusing on a far object, the pupils should dilate (mydriasis). This response indicates that the pupils are adapting to changes in focal distance, demonstrating accommodation.

A. Initiate NPO status. B. Restrict activity to bed rest. C. Monitor urinary output. D. Obtain an electrocardiogram.

Correct Answer is A

Explanation

A) Initiate NPO status: The client's sudden cessation of breathing during deep palpation of the abdomen suggests peritoneal irritation, which could be indicative of a serious condition such as appendicitis or peritonitis. Initiating NPO (nothing by mouth) status is crucial in case emergency surgery is required to address the underlying abdominal pathology. NPO status helps prevent complications such as aspiration if surgery becomes necessary.

B) Restrict activity to bed rest: While bed rest may be indicated for certain abdominal conditions to reduce discomfort and prevent exacerbation of symptoms, it is not the most immediate priority in this scenario. The priority is addressing the potential need for emergency surgery and ensuring the client's safety.

C) Monitor urinary output: Monitoring urinary output is important for assessing hydration status and renal function, but it is not the most critical intervention in this scenario where peritoneal irritation is suspected.

D) Obtain an electrocardiogram: While an electrocardiogram (ECG) may be warranted in certain situations, such as if the client is experiencing chest pain or symptoms suggestive of cardiac involvement, it is not indicated as the most immediate action in this scenario of acute abdominal pain and potential peritoneal irritation.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

To assess a client's pupillary reaction to accommodation, which action should the nurse take?

Correct Answer is D

Explanation

During an abdominal assessment, a client with a temperature of 103° F (39.4° C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement?

Correct Answer is A

Explanation

While completing a health assessment for a client being admitted with bilateral pneumonia, the nurse asks the client to describe the sputum. Which communication technique should the nurse use to obtain this information?

A client is being evaluated for environmental allergies. While examining the client's nasal passage, which finding suggests to the nurse that the client is experiencing allergic rhinitis?

The nurse observes the presence of brittle, concave curves to the nails of a client on assessment. Which information should the nurse obtain from the client that may explain the appearance of the nails?

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?

In assessing a client's neck, the nurse hears a blowing swish when auscultating the area over the left carotid artery, but hears no sound over the right carotid artery. How should the nurse document this finding?

An adolescent female client comes to the clinic troubled by breast tenderness before her menstrual periods. On examination, the nurse notes generalized lumpiness of both breasts with no discrete masses and no nipple discharge. Which action should the nurse take?

Which skill should the nurse have an older client demonstrate to evaluate the ability to perform activities of daily living (ADL)?

The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating. Which finding indicates an expected response when the nurse percusses the costovertebral angle?