To objectively confirm the presence of fever, before taking the client's temperature, which action should the nurse take?
Explanation & Rationale
A. Placing the dorsum (back) of the hand on the client’s forehead is a quick method to assess whether the client feels warm to the touch, which can be an indication of fever. Although not as accurate as taking the temperature, this action is a common preliminary step to confirm the suspicion of fever. B. Lightly pinching a fold of skin over the sternum is a technique used to assess skin turgor and hydration status, not fever. It does not provide information about the client's body temperature. C. Asking the client to describe related symptoms may help gather subjective data but does not objectively confirm the presence of fever. Direct temperature measurement or physical assessment is necessary for objective confirmation. D. Using both hands to hold and palpate the client’s hands may provide information about circulation or warmth, but it is not a reliable method to confirm fever. The forehead is a more appropriate location to assess for elevated temperature.