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.
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Hyperpigmentation is a common manifestation of Addison's disease due to increased production of melanocyte-stimulating hormone along with adrenocorticotropic hormone (ACTH).
Choice B rationale
Purple striations are more characteristic of Cushing's syndrome, not Addison's disease; they result from prolonged exposure to high cortisol levels.
Choice C rationale
Intention tremors are not associated with Addison's disease; they are more commonly related to neurological conditions such as multiple sclerosis or cerebellar disorders.
Choice D rationale
Hirsutism is not typical of Addison's disease but is more related to conditions involving excess androgen production, such as polycystic ovary syndrome (PCOS).
Correct Answer is A
Explanation
Choice A rationale
A raised rash across the nose and face, known as a butterfly rash, is a classic and distinctive manifestation of systemic lupus erythematosus (SLE), often exacerbated by sunlight exposure.
Choice B rationale
Hypothermia is not a common manifestation of SLE; patients more frequently experience fevers due to inflammation and immune system dysregulation.
Choice C rationale
Weight gain is not a typical direct manifestation of SLE; patients might experience weight changes due to medications or complications but not as a primary symptom.
Choice D rationale
Muscle hyperreflexia is not associated with SLE; neurological symptoms in SLE might include seizures or cognitive dysfunction, but not hyperreflexia.
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