A nurse is caring for an adolescent who has hyperthermia.
Which of the following actions should the nurse take?
Cover the adolescent with a thermal blanket
Submerge the adolescent’s feet in ice water
Initiate seizure precautions
Administer oral acetaminophen
The Correct Answer is C
Hyperthermia is a condition in which the body temperature is abnormally high, usually due to exposure to heat, infection, or certain medications.
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.
Choice A is wrong because covering the adolescent with a thermal blanket would increase the body temperature and worsen hyperthermia. The nurse should remove excess clothing and use cooling measures, such as fans, ice packs, or cool fluids.
Choice B is wrong because submerging the adolescent’s feet in ice water would cause vasoconstriction and shivering, which would reduce heat loss and increase heat production. The nurse should avoid using extreme cold or ice water to cool the body.
Choice D is wrong because 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.
Normal body temperature ranges from 36.5°C to 37.5°C (97.7°F to 99.5°F). Hyperthermia is defined as a body temperature above 38.5°C (101.3°F).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Offer to take pictures of the newborn for the client is the right choice, During the initial grieving process after experiencing a stillbirth, the nurse should offer to take pictures of the newborn for the client if the client wishes. Offering to take pictures is an essential and sensitive way to honour and validate the client's experience and the significance of their baby. It allows the client to have tangible memories of their child, which can be important for the grieving process and help in the healing journey.
It is crucial for the nurse to be supportive and compassionate during this time, respecting the client's emotional needs and preferences. Providing emotional support and empathy are critical components of caring for a client who has experienced the loss of a baby.
Choice B reason:
Assure the client that she can have additional children is not correct. While this statement may be well-intentioned, it may not be appropriate during the initial grieving process. The client may not be emotionally ready to discuss future pregnancies, and such assurances might minimize the significance of the loss they are experiencing. It is essential to be sensitive and refrain from making assumptions about the client's feelings or future plans.
Choice C reason:
Avoid talking to the client about the newborn. Avoiding talking to the client about the newborn may be seen as disregarding their feelings and emotions. Instead, it is essential to provide opportunities for the client to talk about their feelings and the baby if they wish to do so. Creating an environment where the client feels comfortable expressing their emotions can be crucial in the grieving process.
Choice D reason
Discouraging the client from allowing friends to see the newborn It is not appropriate for the nurse to discourage or prevent the client from allowing friends to see the newborn if they wish to do so. Grieving is a highly individual process, and some clients may find comfort and support in sharing their grief with loved ones. The nurse should respect the client's decisions regarding who they want to involve in their grieving process.
Correct Answer is ["B","C"]
Explanation
The correct answers are B and C.
Choice A Reason: Transferring a client who is receiving radiation therapy involves understanding the precautions and care associated with radiation, which may be beyond the training of assistive personnel (AP). Radiation therapy clients may have specific safety and transport protocols that require the expertise of licensed nursing staff.
Choice B Reason: Measuring vital signs for a client who requires contact precautions is a task that can be delegated to AP. Assistive personnel can be trained in infection control procedures and the use of personal protective equipment (PPE), making them capable of measuring vital signs while adhering to contact precautions.
Choice C Reason: Recording urine output for a client who has a suprapubic catheter can be delegated to AP. This task involves measuring and documenting a quantifiable data point, which does not require the clinical judgment of a nurse. AP can be trained to accurately measure and record urine output.
Choice D Reason: Planning care for a client who has dysphagia is a complex task that involves assessment and clinical judgment, which are responsibilities of the licensed nurse. Dysphagia can have serious complications, and care plans must be tailored to each client’s needs, requiring the expertise of a nurse.
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