The night nurse is reviewing the vital signs of a client in an extended care facility. The nurse notes the client's oral temperature at 6 a.m. was 98.0°F, but that evening, the client's oral temperature was 99.2°F
The nurse suspects that this variation in temperature is indicative of: 1. The client's temperature has been improperly assessed either in the morning or evening; the nurse can't be sure which.
2. The client is developing an infection.
3. The client is experiencing stress.
4. The client's temperature is demonstrating diurnal variations.
4
Rationale 1: The difference in body temperature is evidence of diurnal variation. Core body temperature is lowest during the early morning and becomes higher during the course of the day.
Rationale 2: There is no evidence to suggest the temperatures were incorrectly assessed and the same routes were used for both assessments.
Rationale 3: There is no evidence to suggest that the client is developing an infection other than the higher evening body temperature.
Rationale 4: There is nothing to suggest that this client is under a great deal of stress which may elevate body temperature.
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