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 {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}
Explanation
-
Vision (Blurred)
- Interpretation: Potential worsening condition
- Rationale: Blurred vision can be a sign of lithium toxicity. Despite the lithium level improving, this symptom indicates that neurotoxicity may still be present.
-
Lithium Level (1.2 mEq/L)
- Interpretation: Potential improvement
- Rationale: The lithium level has decreased from 1.8 mEq/L (toxic) to 1.2 mEq/L, which is within the therapeutic range (0.6-1.2 mEq/L). This indicates that treatment to lower lithium toxicity is effective.
-
Urine Output (40 mL/hr)
- Interpretation: Potential improvement
- Rationale: A urine output of 40 mL/hr is within the acceptable range (normal is greater than 30 mL/hr), suggesting that kidney function is adequate and not compromised by lithium toxicity.
-
Mucous Membranes (Pale, Dry)
- Interpretation: Potential worsening condition
- Rationale: Pale, dry mucous membranes suggest dehydration, which can increase the risk of lithium toxicity and negatively affect overall health.
-
Vital Signs (BP 88/50 mm Hg, Pulse 96/min)
- Interpretation: Potential worsening condition
- Rationale: The drop in blood pressure from 130/84 mm Hg to 88/50 mm Hg indicates hypotension. This could be related to dehydration or lithium toxicity, and it requires follow-up as the condition is deteriorating.
Correct Answer is A
Explanation
Choice A rationale:
Hemorrhagic stroke is characterized by sudden, severe headache, vomiting, and a significant increase in blood pressure, all of which are present in the client. This type of stroke occurs when a weakened blood vessel ruptures and bleeds into the surrounding brain.
Choice B rationale:
Thrombotic stroke is caused by a clot that develops in a blood vessel within the brain. It typically presents with less severe symptoms and a gradual onset, not a sudden one.
Choice C rationale:
Embolic stroke is caused by a clot that travels to the brain from another part of the body. Like thrombotic stroke, it typically has a more gradual onset.
Choice D rationale:
Transient ischemic attack (TIA) is a temporary blockage of blood flow to the brain. It usually lasts less than an hour and does not cause permanent damage.
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