Answer to Question 1
Answer: C, E
Until the client has orders written, the nurse can apply cool washcloths to the client's face and neck to increase comfort and reduce the client's body temperature. The nurse can also reduce clothing and skin covering by loosening clothing around the neck and chest. Warm blankets and fluid restriction would keep the temperature elevated rather than helping to decrease it.. Assessing vital signs is important; however, the nurse needs to intervene to help bring the body temperature down.
Answer to Question 2
Answer: B, D
Evidence that interventions have been effective for a client with an elevated body temperature includes moist mucous membranes and good skin turgor. Urine output of 20 ml/hour indicates dehydration. Blood pressure of 118/68 mmHg is not an indication of the control of fever. A heart rate of 120 beats per minute could indicate dehydration.