A nurse is assessing a client who has hypothermia. Which of the following findings should the nurse identify as a manifestation of hypothermia?
Impaired coordination
Sensitivity to light
Increased respiratory rate
Hypertension
The Correct Answer is A
A) Impaired coordination:
Impaired coordination is a common manifestation of hypothermia. As the body temperature drops, the nervous system is affected, leading to difficulties in motor control and coordination. This symptom is indicative of the body's struggle to maintain normal physiological functions in response to the cold.
B) Sensitivity to light:
Sensitivity to light is not typically associated with hypothermia. This symptom is more commonly related to conditions affecting the eyes or the central nervous system, such as migraines or meningitis.
C) Increased respiratory rate:
Hypothermia generally leads to a decreased respiratory rate as the body's metabolic processes slow down. An increased respiratory rate is not a common symptom and may indicate another underlying condition or a compensatory mechanism for another issue.
D) Hypertension:
Hypertension is not a typical manifestation of hypothermia. In fact, as hypothermia progresses, the body's blood pressure often decreases due to reduced cardiac output and peripheral vasoconstriction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Initiate frequent, short periods of exercise throughout the day: Frequent, short periods of exercise are beneficial for a client with left-sided hemiplegia. Regular movement helps maintain joint flexibility, muscle strength, and overall functional ability. This approach can prevent complications such as contractures and muscle atrophy.
B) Decrease the amount of range of motion performed if tightness occurs: If tightness occurs, rather than decreasing range of motion, it is important to address it through appropriate stretching and adjustments in exercise technique. Reducing range of motion could lead to further loss of mobility and function.
C) Perform range-of-motion exercises to the affected side once per day: Performing range-of-motion exercises only once per day is generally insufficient. To maintain or improve mobility and prevent contractures, range-of-motion exercises should be performed multiple times throughout the day, as directed by the care plan.
D) Avoid repetitive movements during exercise: Repetitive movements are not necessarily harmful and can be beneficial for improving motor function and muscle coordination. However, it is important to balance repetitive exercises with variety and adjust based on the client’s condition and tolerance.
Correct Answer is D
Explanation
A) Decrease folic acid intake: Decreasing folic acid intake is not advisable for clients with malabsorption syndrome. In fact, clients with malabsorption often require increased folic acid due to poor absorption of nutrients, especially in conditions like celiac disease or other causes of malabsorption.
B) Increase lactose intake: Increasing lactose intake is not appropriate for clients with malabsorption syndrome, particularly if they have lactose intolerance. Lactose can exacerbate symptoms such as diarrhea and steatorrhea in these clients.
C) Provide a gluten-free diet: A gluten-free diet is crucial for clients with celiac disease, which is a type of malabsorption syndrome. However, if the malabsorption syndrome is due to another cause, a gluten-free diet might not address the issue. The focus should be on managing fat intake to reduce steatorrhea.
D) Provide a low-fat diet: A low-fat diet is the most appropriate intervention for managing severe steatorrhea, which is the presence of excess fat in the stool. Reducing fat intake helps to minimize fat malabsorption and the associated symptoms, providing relief from steatorrhea.
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