A nurse is cheering on participants in a marathon and one runner collapses nearby. He begins to vomit and complain of a throbbing headache. The nurse notes that he is not sweating, yet his skin is red and very hot to touch, and his pulse is 170 bpm and strong. The nurse knows that:
The runner may lose consciousness due to heat stroke.
It is not necessary to call 911.
It is normal to vomit and not sweat during a marathon.
Getting the patient to a cooler, air-conditioned place will reverse the heat exhaustion.
The Correct Answer is A
Some of the symptoms of heat stroke are:
• High body temperature of 104 F (40 C) or higher
• Altered mental state or behavior, such as confusion, agitation, slurred speech, seizures or coma
• Lack of sweating despite the heat
• Red, hot and dry skin
• Rapid and strong pulse
• Throbbing headach
• Nausea and vomiting
Choice B is wrong because it is necessary to call 911 if someone has heat stroke. Heat stroke is a medical emergency that requires immediate attention and cooling of the body.
Choice C is wrong because it is not normal to vomit and not sweat during a marathon. Vomiting and lack of sweating are signs of dehydration and heat stroke, which indicate that the body is unable to regulate its temperature properly.
Choice D is wrong because getting the patient to a cooler, air-conditioned place will not reverse the heat exhaustion.
Heat exhaustion is a milder form of heat-related illness that can lead to heat stroke if not treated. Heat exhaustion symptoms include heavy sweating, weakness, dizziness, nausea and muscle cramps. Getting the patient to a cooler place may help with heat exhaustion, but heat stroke requires more aggressive cooling measures such as immersing the patient in cold water or applying ice packs to the body.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This demonstrates advocacy for client rights because it respects the client’s autonomy, dignity, and preferences. It also helps the client to make informed decisions about their own health.
Choice B is wrong because telling the client that refusal of the medication is considered noncompliance is coercive and violates the client’s right to refuse treatment.
It also does not address the client’s reasons for refusing the medication or provide any information or education.
Choice C is wrong because informing the client that the medication is the same as taken at home is not enough to ensure that the client understands the purpose, benefits, and risks of the medication.
It also does not verify that the client is taking the medication correctly at home or that there are no changes in the dosage or frequency.
Choice D is wrong because insisting the client takes the prescribed medications is also coercive and violates the client’s right to refuse treatment.
It also does not respect the client’s autonomy, dignity, and preferences.
It may also cause harm to the client if they have an allergy, intolerance, or contraindication to the medication.
Advocacy for nursing stems from a philosophy of nursing in which nursing practice is the support of an individual to promote his or her own well-being, as understood by that individual. It is an ethic of practice that requires nurses to protect and uphold their patients’ rights, values, and interests.
Correct Answer is ["A","B"]
Explanation
A cultural assessment is a systematic way to identify the beliefs, values, meanings, and behaviours of people while considering their history, life experiences, and social and physical environments. A nurse should include reviewing all ordered treatments in relation to the client’s culture and listening to the client’s perceptions as part of a cultural assessment.
These actions show respect for the client’s preferences and facilitate communication and understanding.
Choice C is wrong because explaining the purpose of the treatments without regard to the client’s culture may be insensitive or inappropriate for some clients who have different beliefs or practices about health and illness. Choice D is wrong because acknowledging that the client will have to adapt their perceptions to the dominant culture may be disrespectful or oppressive for some clients who value their cultural identity and diversity.
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