the nurse is caring for a 65 year old client and notes a temperature of 101f how does the nurse interpret this finding
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Nursing Elites

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. The nurse is caring for a 65-year-old client and notes a temperature of 101�F. How does the nurse interpret this finding?

Correct answer: A

Rationale: A temperature of 101�F is indicative of hyperthermia, which is an elevated body temperature. Hyperthermia is commonly associated with fever or environmental factors such as excessive heat exposure. Choice B, 'A cold environment,' is incorrect as hyperthermia refers to elevated body temperature, not a cold environment. Choice C, 'Normal,' is incorrect as a temperature of 101�F is above the normal range for body temperature. Choice D, 'Hypothermia,' is incorrect as hypothermia refers to a low body temperature, not an elevated one.

2. During a skin inspection at the outpatient clinic, the nurse notices patches of thick, red skin with silvery scales on the client's elbows and knees. What skin abnormality does the nurse suspect?

Correct answer: C

Rationale:

3. The nurse is preparing communication for a provider. The client is experiencing acute pain greater than the severity of the fracture. Distal to the injury, he is experiencing a 'pins and needles' sensation. The pulse is weak and thready but is bounding on all unaffected extremities. What emergent condition does the nurse suspect?

Correct answer: B

Rationale:

4. A client states that he has been experiencing oozing from his wounds. What is the nurse's priority action?

Correct answer: D

Rationale:

5. What is the priority nursing diagnosis for a client with metastatic bone disease?

Correct answer: C

Rationale: The correct answer is 'Risk for falls.' In clients with metastatic bone disease, weakened bones can lead to an increased risk of falls, making it a priority nursing diagnosis. Chronic pain (choice A) may be present but addressing the risk for falls is more critical in this situation. While impaired mobility (choice B) can be a consequence of metastatic bone disease, preventing falls takes precedence. Risk for infection (choice D) is not the priority in this case, as falls pose a more immediate threat to the client's safety.

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