An male client 86 years of age with a diagnosis of vascular dementia and cardiomyopathy is exhibiting signs and symptoms of pneumonia
The nurse has attempted to assess his temperature using an oral thermometer, but the client is unable to follow directions to close his mouth and secure the thermometer sublingually. Additionally, he repeatedly withdraws his head when the nurse attempts to use a tympanic thermometer. How should the nurse proceed with this assessment?
A) Assess the client's temperature by axilla.
B) Assess the client's skin tone and the presence or absence of sweating to determine whether the client is febrile.
C) Use a disposable mercury thermometer to take the client's temperature.
D) Take the client's temperature rectally.
Ans: A
The axillary site is an accurate and acceptable alternative when other sites are impractical or contraindicated. Rectal temperatures are contraindicated in cardiac clients; mercury thermometers are not commonly used. It is unacceptable for the nurse to rely solely on subjective assessments to determine whether the client is febrile.
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