A nurse is caring for a client who has meningitis, a temperature of 39.7° C (103.5° F) and is prescribed a hypothermia blanket.
While using this therapy, the nurse should know that the client must carefully be observed for which of the following complications?
Dehydration.
Shivering.
Seizures.
Burns.
The Correct Answer is B
The correct answer is choice B: Shivering.
Choice A rationale: Dehydration is a risk associated with high fever and infections like meningitis, but it is not a direct complication of using a hypothermia blanket.
Choice B rationale: Shivering is a complication of using a hypothermia blanket, as the body may react to the induced cooling by shivering, which can raise body temperature and counteract the blanket's cooling effect.
Choice C rationale: Seizures can occur in meningitis cases, but they are not specifically a complication of using a hypothermia blanket.
Choice D rationale: Burns are not a typical complication of using a hypothermia blanket when it is used as directed and monitored appropriately. However, skin irritation may occur in some cases.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
An HbA1c value of 8.5% is above the recommended range for good glucose control.
Choice B rationale:
An HbA1c value of 6.3% is within the target range for people with diabetes, indicating good glucose control.
Choice C rationale:
An HbA1c value of 10% is significantly above the recommended range, indicating poor glucose control.
Choice D rationale:
An HbA1c value of 7.8% is above the recommended range for good glucose control.
Correct Answer is []
Explanation
Condition Most Likely Experiencing:
Delirium
- Explanation: The client has acute confusion, disorganized thinking, restlessness, incoherent speech, and altered sleep-wake cycle—all classic signs of delirium. The sudden onset (starting the previous evening) and fever (38.6°C) suggest a potential underlying cause, such as infection or dehydration.
Actions to Take:
Monitor the client's fluid intake and output.
- Explanation: The client has severe fluid imbalance (250 mL intake vs. 2,500 mL output), leading to dehydration, which can contribute to delirium. Monitoring intake and output is critical for managing hydration status.
Encourage family members to stay with the client.
- Explanation: Familiar faces can help reorient the client and reduce agitation. Delirium often improves with familiar environmental cues and reassurance.
Parameters to Monitor:
Sleep-wake cycle.
- Explanation: Disrupted sleep patterns are a key symptom of delirium. Tracking sleep can help assess improvement or worsening of the condition.
Fall risk.
- Explanation: The client is attempting to get out of bed without assistance, which puts them at high risk for falls. Close monitoring is essential to prevent injury.
Incorrect Choices and Explanations:
Request a prescription for benzodiazepine.
- Why Incorrect? Benzodiazepines can worsen delirium, especially in older adults, by increasing confusion and fall risk.
Assist the client to identify coping skills.
- Why Incorrect? Delirium is an acute medical condition, not a psychological disorder. The focus should be on treating the underlying cause, not psychological coping strategies.
Encourage the client to exercise.
- Why Incorrect? The client is confused, weak, and at risk of falls. Exercise is not appropriate at this stage.
BUN level.
- Why Incorrect? While kidney function (BUN) could be affected by dehydration, monitoring fluid balance directly (intake/output) is more immediate and relevant.
Weight loss.
- Why Incorrect? While the client has refused to eat or drink, weight loss occurs over time, whereas the primary concern is acute dehydration and delirium.
Suicidal ideation.
- Why Incorrect? There is no indication of suicidal thoughts. The confusion and agitation are more likely due to delirium than depression.
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