A nurse is caring for a male client, 58 years old, in the emergency department who is suspected of having heatstroke. The primary health care provider has ordered a series of diagnostic tests and interventions. Below are the exhibits to help the nurse assess the client.

Exhibits

The nurse is caring for a male client suspected of having heatstroke. Which findings are consistent with this diagnosis? (Select all that apply.)

Tachycardia

Hallucinations

Skin is hot, dry

Bradycardia

Answer and Explanation

Correct Answer : A,C

Choice A rationale:
Tachycardia: Heatstroke often leads to an elevated heart rate due to the body's attempt to cool down and compensate for increased body temperature. The heart rate of 120 beats per minute noted in the client is consistent with tachycardia.
Choice B rationale:
Hallucinations: While confusion and disorientation are common symptoms of heatstroke, hallucinations are not typical findings associated with heatstroke. Therefore, this is not a consistent finding for this diagnosis.
Choice C rationale:
Skin is hot, dry: One of the hallmark signs of heatstroke is hot, dry skin, which results from the body's inability to regulate its temperature effectively. The client's skin being hot to the touch and dry aligns with this characteristic.
Choice D rationale:
Bradycardia: This is characterized by a slower than normal heart rate. Since the client presents with a heart rate of 120 beats per minute, which indicates tachycardia, bradycardia is not a finding consistent with heatstroke.

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Correct Answer is A

Explanation

Choice A rationale
Muscle wasting and osteoporosis are common findings in Cushing's syndrome due to prolonged exposure to high levels of cortisol, which leads to the breakdown of muscle tissue and decreases in bone density.
Choice B rationale
Diaphoresis is not a typical feature of Cushing's syndrome. While excessive sweating can occur in various conditions, it is not a hallmark of Cushing's syndrome, which primarily affects muscle, bone, and fat distribution.
Choice C rationale
Hypotension is not characteristic of Cushing's syndrome. Instead, hypertension is more common due to cortisol's effects on increasing blood pressure through sodium and water retention.
Choice D rationale
Weight loss is not a typical finding in Cushing's syndrome. Individuals with Cushing's syndrome often experience weight gain, particularly around the abdomen, face, and neck, due to cortisol's effects on fat distribution.

A. Restrict foods containing potassium. B. Give sodium polystyrene sulfonate for hypokalemia. C. Keep urine pH below 7.0. D. Restrict all oral fluids.

Correct Answer is A

Explanation

Choice A rationale
Restricting foods containing potassium helps prevent hyperkalemia, a common metabolic imbalance in tumor lysis syndrome (TLS) due to the rapid release of intracellular potassium from lysed tumor cells.
Choice B rationale
Giving sodium polystyrene sulfonate is used to treat hyperkalemia, not hypokalemia. It works by binding potassium in the gut and helping excrete it from the body, but it is not a preventive measure for metabolic imbalances in TLS.
Choice C rationale
Keeping urine pH below 7.0 is not recommended for TLS. Alkalinizing the urine to a pH above 7.0 helps prevent uric acid crystallization and renal damage, which is crucial in managing TLS.
Choice D rationale
Restricting all oral fluids is not advisable for TLS. Adequate hydration is essential to support kidney function and enhance the excretion of electrolytes and uric acid, which helps prevent and manage TLS.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has Cushing's syndrome. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A patient has been admitted with tumor lysis syndrome (TLS). Which intervention would be incorporated into the plan of care to prevent the metabolic imbalances associated with this disorder?

Correct Answer is A

Explanation

A nurse is teaching a female client who has a new diagnosis of systemic lupus erythematosus (SLE). The nurse should recognize the need for further teaching when the client identifies which of the following as a factor that can exacerbate SLE?

A nurse is caring for a client who has nausea and a prescription for metoclopramide intermittent IV bolus every 4 hours as needed. The client asks the nurse how metoclopramide will relieve her nausea. Which of the following explanations should the nurse provide?

A nurse is providing dietary teaching for a client who has Cushing's disease. Which of the following recommendations should the nurse include in the teaching?

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A nurse is caring for a client who has a history of Addison's disease and is in Addisonian crisis. The client is lethargic. Which of the following actions should the nurse take?

A nurse is caring for a client who has Cushing's syndrome.Which of the following interventions should the nurse expect to perform? (Select all that apply.)

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