Which nursing assessment finding in an elderly client with sepsis requires immediate intervention?

Take her temperature at the same time every morning before getting out of bed.

Explanation:
The basal body temperature method requires that the client take her temperature each morning before getting out of bed, preferably at the same time each day before eating or any other activity. Just before the day of ovulation, the temperature falls by 0.5° F (0.28° C). At the time of ovulation, the temperature rises 0.4°F to 0.8°F (0.22°C to 0.44°C) because of increased progesterone secretion in response to the luteinizing hormone. The temperature remains higher for the rest of the menstrual cycle. The client should keep a diary of about 6 months of menstrual cycles to calculate "safe" days. There is no mucus for the first 3 or 4 days after menses, and then thick, sticky mucus begins to appear. As estrogen increases, the mucus changes to clear, slippery, and stretchy. This condition, termed spinnbarkeit, is present during ovulation. After ovulation, the mucus decreases in amount and becomes thick and sticky again until menses. Because the ovum typically survives about 24 hours and sperm can survive up to 72 hours, couples must avoid coitus when the cervical mucus is copious and for about 3 to 4 days before and after ovulation to avoid a pregnancy.

Vesicles
Explanation:
Vesicles are raised, round, serous-filled lesions that are usually less than 1 cm in diameter. Examples of vesicles include chickenpox (varicella) and shingles (herpes zoster). A pustule is a raised, circumscribed lesion that's usually less than 3/8″ in diameter and contains purulent material that gives it a yellow-white color — for example, acne pustule and impetigo. A plaque is a circumscribed, solid, elevated lesion that's more than 3/8″, in diameter — for example, psoriasis. A papule is a firm, inflammatory, raised lesion that's as long as 1/4″ in diameter and that may be pigmented or the same color as the client's skin — for example, acne papule and lichen planus.

ECG (electrocardiogram), complete blood count, testing for occult blood, and comprehensive serum metabolic panel.

Explanation:
An ECG evaluates the report of chest pain, laboratory tests determine anemia, and the test for occult blood determines blood in the stool. Cardiac monitoring, oxygen, and creatine kinase and LD levels are appropriate for a primary cardiac problem. A basic metabolic panel and alkaline phosphatase and aspartate aminotransferase levels assess liver function. PT, PTT, fibrinogen, and fibrin split products are measured to verify bleeding dyscrasias. An EEG evaluates brain electrical activity.

-bradycardia
- weakness

Explanation:
To assess pain properly, the nurse must consider the client's description and the nurse's observations of the client's physical and behavioral responses. Physiologic responses may be sympathetic or parasympathetic in nature. Sympathetic responses are commonly associated with mild to moderate pain and include pallor, elevated blood pressure, dilated pupils, skeletal muscle tension, dyspnea, tachycardia, and diaphoresis. Parasympathetic responses are commonly associated with severe, deep pain and include pallor, decreased blood pressure, bradycardia, nausea and vomiting, weakness, dizziness, and loss of consciousness.

When assessing an elderly client the nurse expects to find various aging related physiologic changes These changes include?

Reason: Aging-related physiologic changes include delayed gastric emptying, decreased coronary artery blood flow, an increased posterior thoracic curve, and increased peripheral resistance.

What is head to toe assessment in nursing?

Simply put, a head to toe assessment is an exhaustive process that checks the health status of all major body systems. It is a comprehensive physical examination that shines a light on a patient's needs and problems.

Which client should the nurse assess first?

The nurse receives report on 4 assigned clients. Which client should the nurse assess first? 37% of people answered this question correctly. The nurse should first assess the client showing symptoms of a deep venous thrombosis (DVT) (eg, unilateral edema , warmth, redness , tenderness on palpation).

Which of the following questions would the nurse ask the client when evaluating his preoperative cognitive perceptual pattern?

When evaluating a client's preoperative cognitive-perceptual pattern, which question should the nurse ask the client? "Do you wear glasses?" You just studied 159 terms!

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