A nurse is caring for a client who is febrile. To reduce the client's fever, the nurse applies a cooling blanket. Which of the following findings indicates the client is having an adverse reaction to the cooling?

Tachycardia

Shivering

Flushing

Restlessness

Answer and Explanation

The Correct Answer is B

A: Tachycardia might occur due to the fever itself but isn't a specific reaction to the cooling method.
B: Shivering is an adverse reaction because it indicates that the body is trying to generate heat to counteract the cooling effect of the blanket, which can increase metabolic demand and is counterproductive.
C: Flushing is typically related to fever or other causes but not directly to the adverse reaction of cooling.
D: Restlessness can be caused by discomfort or the fever itself, not specifically by cooling.

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Correct Answer is B

Explanation

A. Administering oral acetaminophen would not be effective for hyperthermia caused by non-infectious factors, such as heat exposure or medications. Acetaminophen lowers the body temperature by reducing the hypothalamic set point, which is not altered in hyperthermia. Additionally, oral medications may be difficult to swallow or absorb in a hyperthermic patient.

B. Hyperthermia can cause neurological complications, such as seizures, confusion, or coma. Therefore, the nurse should initiate seizure precautions for an adolescent who has hyperthermia to prevent injury and protect the airway.
C. Submerging the feet in ice water is not recommended as it can cause vasoconstriction and shivering, which may increase the body temperature. Instead, tepid sponging and providing a cool environment can be beneficial.
D. Covering the adolescent with a thermal blanket would retain body heat and exacerbate hyperthermia, counteracting efforts to lower the body temperature.

A. A client who has Clostridium difficile and a temperature of 38.6° C (101.5° F) B. A client who has a complete femur fracture and reports a pain level of 7 on a scale from 0 to 10 C. A client who has left shoulder pain and S-T elevation on a 12-lead ECG D. A client who has orthostatic hypotension and 4+ pitting edema in the lower extremities

Correct Answer is C

Explanation

A. While a temperature elevation in a client with Clostridium difficile requires assessment, it is not as urgent as potential cardiac ischemia.
B. Pain assessment in a client with a femur fracture is important but does not take priority over potential cardiac issues.
C. Left shoulder pain with S-T elevation on an ECG can indicate myocardial infarction (MI), a life-threatening condition requiring immediate assessment and intervention.
D. Orthostatic hypotension and pitting edema, while concerning, do not indicate an acute, life-threatening condition that requires immediate assessment in this scenario.

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A nurse is caring for a client who is febrile. To reduce the client's fever, the nurse applies a cooling blanket. Which of the following findings indicates the client is having an adverse reaction to the cooling?

Nursing Test Bank

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