The nurse is assessing a toddler when the child's mother tells the nurse that the child has had a fever for the past two days
When the nurse asks the mother what the temperature has been, the mother replies that she hasn't actually taken it but the child's skin has felt very warm. Which of the following would be the most appropriate response for the nurse? 1. "When our skin feels warm, it means our blood vessels are constricted."
2. "The only reliable indicator of body temperature is by feeling the forehead."
3. "Our skin temperature changes when our surroundings change temperature."
4. "The temperature of the skin is not related to what is happening inside our bodies."
3
Rationale 1: Fever causes vasodilation, not vasoconstriction.
Rationale 2: When fever is present, the skin all over the body may feel warm, not just the forehead, thus the only reliable indicator of body temperature is measuring the core temperature with a thermometer.
Rationale 3: The surface temperature of the body is constantly changing in response to environmental influences and as a result is not a reliable indicator of actual health status. To obtain accurate temperature, the core temperature, or the temperature of the deep tissues of the body, needs to be assessed.
Rationale 4: The temperature of the skin is related to what is happening inside the body. Fever is a sign of the disruption of homeostasis in the body. This may be due to a bacterial or viral infection. Fever causes vasodilation, which can make the skin feel warm to the touch.
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