A nurse at an urgent care center is assisting with the care of a client who has hypothermia after exposure to frigid water. Which of the following actions should the nurse take first?

Apply a heating pad to the client's neck.

Provide the client with dry clothing.

Offer the client a warm beverage.

Wrap the client in warm blankets.

Answer and Explanation

The Correct Answer is B

A. Apply a heating pad to the client's neck: Direct application of heat to the skin, especially in localized areas like the neck, can cause rapid vasodilation, leading to a dangerous drop in blood pressure and potential cardiac complications. It also increases the risk of burns on cold-numbed skin.

B. Provide the client with dry clothing: Removing wet clothing and replacing it with dry garments is the first priority in managing hypothermia. Wet clothes accelerate heat loss through conduction and evaporation. Stopping further heat loss is essential before attempting active rewarming.

C. Offer the client a warm beverage: While offering warm fluids can help increase core temperature and provide comfort, it is not the first priority. This intervention is more appropriate after ensuring the client is dry and wrapped in warm coverings.

D. Wrap the client in warm blankets: Wrapping the client in warm blankets is a critical intervention for passive external rewarming. However, it comes after the initial step of removing wet clothes to prevent ongoing heat loss. Blankets are most effective once the source of heat loss has been eliminated.

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Correct Answer is C

Explanation

A. "Why do you think they're not eating?”: This question may come across as confrontational or accusatory, which can make the child feel defensive. It does not foster open communication or help the nurse gather specific, objective information.

B. "They may need a feeding tube.": Introducing a feeding tube early in the discussion can cause unnecessary alarm. It is a significant intervention that should only be considered after a thorough assessment and evaluation by the provider.

C. "Tell me more about what happens at mealtime.": This open-ended, nonjudgmental question encourages the child to provide detailed information about the client's eating habits, environment, and possible stressors, helping the nurse assess the situation more effectively.

D. "I'm sure it's nothing serious and their appetite will return soon.": This response is dismissive and minimizes the child’s concern. It may hinder further communication and delay identifying potential underlying issues with the client's nutrition.

A. Have the client perform heel-to-toe walking. B. Perform Weber's test. C. Check for a positive Babinski reflex. D. Perform the Romberg test. E. Have the client lie in bed and use his heel to draw a line on the opposite shin.

Correct Answer is ["A","D","E"]

Explanation

A. Have the client perform heel-to-toe walking: Heel-to-toe walking (tandem gait) assesses balance and coordination by challenging the client’s ability to maintain stability during a narrow base of support. Difficulty with this test can indicate problems with cerebellar function or proprioception, which are essential for balance.

B. Perform Weber’s test: Weber’s test evaluates hearing by assessing bone conduction and is not related to balance assessment. It helps differentiate between conductive and sensorineural hearing loss but does not provide information about vestibular function.

C. Check for a positive Babinski reflex: Babinski reflex testing assesses neurological function of the corticospinal tract but does not evaluate balance. A positive Babinski indicates upper motor neuron damage but is unrelated to equilibrium or postural control.

D. Perform the Romberg test: The Romberg test evaluates proprioception and balance by assessing the client’s ability to maintain standing posture with eyes closed. A positive Romberg sign suggests impaired proprioception or vestibular dysfunction affecting balance.

E. Have the client lie in bed and use his heel to draw a line on the opposite shin: This test evaluates coordination and proprioception, important components of balance, by assessing precise lower limb control. Difficulty performing this task may indicate issues with neuromuscular control or proprioception.

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A nurse at an urgent care center is assisting with the care of a client who has hypothermia after exposure to frigid water. Which of the following actions should the nurse take first?

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