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 B
Explanation
Choice A rationale
An RBC count of 5 million/mm³ is within the normal range for adult females, so this finding would not be concerning in the context of chemotherapy.
Choice B rationale
A WBC count of 2300/mm³ is significantly lower than the normal range (typically 4500 to 11000/mm³) and indicates neutropenia, which is a critical side effect of chemotherapy that needs to be reported immediately.
Choice C rationale
Hemoglobin level of 12 g/dL is within the normal range for adult females, so this would not be concerning in the context of chemotherapy.
Choice D rationale
A platelet count of 155,000/mm³ is within the normal range (150,000 to 450,000/mm³). Although on the lower end, it is not typically alarming enough to report immediately in the context of chemotherapy.
Correct Answer is D
Explanation
Choice A rationale
Cervical cancer screening is recommended for individuals with a cervix starting at age 21, not necessarily for detecting colorectal cancer. It's an essential screening but irrelevant to middle-aged clients discussing colorectal cancer risk.
Choice B rationale
Lung cancer screening is mainly for people with a history of heavy smoking. Discussing lung cancer screening with a doctor is vital, but it does not address the early detection of colorectal cancer for average-risk individuals.
Choice C rationale
The previous recommendation was to start colorectal cancer screening at age 50. However, guidelines have updated, and this age is now considered outdated for average-risk individuals.
Choice D rationale
Colorectal cancer screening for everyone beginning at age 45 aligns with the latest American Cancer Society guidelines. This change reflects evidence showing the benefit of earlier screening to detect and prevent colorectal cancer in average-risk adults.
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