A nurse is caring for a client who has meningitis and a temperature of 39.7°C (103.5°F). The client is prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client must be carefully observed for which of the following complications?
Dehydration
Burns
Shivering
Seizures
The Correct Answer is C
Choice A reason: Dehydration is a concern with fever, but it is not a direct complication of hypothermia blanket therapy. It is important to ensure adequate hydration, but the primary concern with hypothermia therapy is not dehydration.
Choice B reason: Burns could occur if the hypothermia blanket malfunctions or is used improperly. However, modern devices have safety features to prevent burns, making this a less likely complication.
Choice C reason: Shivering is a natural response to cooling and can occur as the body attempts to generate heat in response to the lowered temperature from the hypothermia blanket. It can be counterproductive to the therapy and may need to be controlled with medications.
Choice D reason: Seizures are not a typical complication of hypothermia blanket therapy. While meningitis can cause seizures due to inflammation of the brain, the hypothermia blanket itself does not induce seizures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Placing the client in a sitting position helps to lower blood pressure by promoting venous return and is the first action to take in cases of autonomic dysreflexia.
Choice B reason: Checking for a fecal impaction is important as it can be a trigger for autonomic dysreflexia, but it is not the first action to take.
Choice C reason: Examining for areas of skin breakdown is part of ongoing care for clients with spinal cord injuries but is not the immediate priority in autonomic dysreflexia.
Choice D reason: Checking blood pressure is important for monitoring the severity of autonomic dysreflexia, but the first action is to address the positioning of the client to manage the hypertensive crisis.
Correct Answer is B
Explanation
Choice A reason: Establishing short-term, realistic goals is important, but it should come after assessing the client's current knowledge. Goals should be tailored to the individual's needs and understanding.
Choice B reason: Assessing the client's current knowledge about managing diabetes is crucial as the first step. This allows the nurse to identify any gaps in understanding and to provide education that is specific to the client's needs.
Choice C reason: Providing access to a video about diabetes can be a useful educational tool, but it should not be the first action. The content of the video may not address the client's specific questions or misconceptions.
Choice D reason: Evaluating the effectiveness of the client's admission teaching plan is an ongoing process and should be done after initial education and interventions have been provided.
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