A nurse is assessing an older client for the presence of ...

[newbem]

A nurse is assessing an older client for the presence of infection. The client's temperature is 97.6  F (36.4  C). What response by the nurse is best?
 
  a. Assess the client for more specific signs.
  b. Conclude that an infection is not present.
  c. Document findings and continue to monitor.
  d. Request that the provider order blood cultures.

Question 2

The student nurse learns that the most important function of inflammation and immunity is which purpose?
 
  a. Destroying bacteria before damage occurs
  b. Preventing any entry of foreign material
  c. Providing protection against invading organisms
  d. Regulating the process of self-tolerance

[ntsoane kedibone]

Answer to Question 1

ANS: A
Because older adults have decreased immune function, including reduced neutrophil function, fever may not be present during an episode of infection. The nurse should assess the client for specific signs of infection. Documentation needs to occur, but a more thorough assessment comes first. Blood cultures may or may not be needed depending on the results of further assessment.

Answer to Question 2

ANS: C
The purpose of inflammation and immunity is to provide protection to the body against invading organisms, whether they are bacterial, viral, protozoal, or fungal. These systems eliminate, destroy, or neutralize the offending agents. The cells of the immune system are the only cells that can distinguish self from non-self. This function is generalized and incorporates destroying bacteria, preventing entry of foreign invaders, and regulating self-tolerance.