intermittent fevers are

NCLEX-RN

NCLEX RN Actual Exam Test Bank

1. Intermittent fevers are:

A. fevers which come and go.
B. fevers which rise and fall but are always considered above the patient's average temperature.
C. fevers which fluctuate more than three degrees and never return to normal.
D. None of the above.

Correct answer: A

Rationale: Intermittent fevers are characterized by periods of fever followed by periods of normal body temperature. They alternate between being febrile and afebrile. Continuous fevers show minimal fluctuations over a 24-hour period, while remittent fevers fluctuate significantly but do return to normal body temperature. Choice A is correct as it accurately describes intermittent fevers. Choices B and C are incorrect as they do not fully capture the defining characteristic of intermittent fevers, which involve cyclical episodes of fever and normal temperature. Choice D is incorrect as there is a specific definition for intermittent fevers.

2. When examining an older adult, which technique should the nurse use?

A. Minimize touching the patient as much as possible.
B. Attempt to perform the entire physical examination during one visit.
C. Speak loudly and slowly due to potential hearing deficits in aging adults.
D. Arrange the sequence of the examination to allow as few position changes as possible.

Correct answer: D

Rationale: When examining an older adult, it is crucial to arrange the sequence of the examination to minimize position changes. This helps prevent discomfort and fatigue for the older adult, who may have mobility issues. Option A is incorrect because physical touch is essential when examining older adults, as their other senses may be diminished. Option B is incorrect as it is better to break the examination into multiple visits to ensure thoroughness and comfort. Option C is incorrect because while some older adults may have hearing deficits, it is not appropriate to assume this for all individuals without proper assessment.

3. During an office visit, the healthcare provider is assessing a patient's skin. What part of the hand and technique would be used to best assess the patient's skin temperature?

A. Fingertips
B. Dorsal surface of the hand
C. Ulnar portion of the hand
D. Palmar surface of the hand

Correct answer: B

Rationale: The correct answer is the dorsal surface of the hand. The dorsa (backs) of the hands and fingers are best for determining temperature because the skin is thinner on the dorsal surfaces than on the palms. Fingertips are best for fine, tactile discrimination and not for assessing skin temperature. The ulnar and palmar surfaces of the hands are not as effective for assessing skin temperature as the dorsal surface because they have thicker skin layers.

4. As a valued member of the team on your nursing care unit, you are trying to determine whether the team is doing well. Which of the following is a sign that your team is successful?

A. Conflict occurs but is seen as an opportunity for team growth and development.
B. No negative feelings are expressed, leading to everyone being happy and satisfied.
C. Mistakes are not tolerated and result in disciplinary action.
D. People avoid taking risks and stick to the status quo.

Correct answer: A

Rationale: One of the key indicators of a successful team is the ability to handle conflict positively. Conflict, when managed well, can lead to team growth and development. Choice B is incorrect because suppressing negative feelings does not indicate team success; open communication is crucial. Choice C is incorrect as successful teams view mistakes as learning opportunities rather than resorting to disciplinary action. Choice D is incorrect because successful teams are often innovative and willing to take risks rather than maintaining the status quo.

5. A triage nurse has four clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first?

A. A 2-month-old infant with a history of rolling off the bed and having a bulging fontanelle with crying
B. A teenager who suffered singed facial hair while camping
C. An elderly client with complaints of frequent liquid brown-colored stools
D. A middle-aged client with intermittent pain behind the right scapula

Correct answer: B

Rationale: The correct answer is the teenager who suffered singed facial hair while camping. This client is in the greatest danger with a potential risk of respiratory distress. Singed facial hair indicates exposure to heat or fire in close range, which could have caused serious damage to the interior of the lungs. It's crucial to prioritize this client as the interior lining of the lungs has no nerve fibers, so swelling may not be immediately noticeable. The other choices, while concerning, do not present an immediate life-threatening situation. The infant's condition may be serious but does not pose an immediate danger of respiratory distress. The elderly client's symptoms could indicate gastrointestinal issues, which are important but not as urgent as potential respiratory compromise. The middle-aged client's pain behind the right scapula, while uncomfortable, does not indicate an acute life-threatening condition requiring immediate attention.