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","C","D","E"]
Explanation
These are some of the criteria used to assist in making the diagnosis of chronic fatigue syndrome (CFS) according to the Institute of Medicine (IOM) 2015 report.
Choice B is wrong because recent exposure to influenza is not a criterion for CFS diagnosis. Although some cases of CFS may be triggered by viral infections, such as Epstein-Barr virus or human herpes virus 6, there is no specific evidence that influenza causes CFS.
Choice A is correct because CFS is not caused by a primary condition. CFS is a diagnosis of exclusion, meaning that other possible causes of fatigue, such as sleep disorders, anemia, diabetes, thyroid problems, or mental health issues, must be ruled out before making the diagnosis.
Choice C is correct because unrefreshing sleep is one of the required symptoms for CFS diagnosis. Patients with CFS may not feel better or less tired even after a full night of sleep despite the absence of specific objective sleep alterations. Choice D is correct because fatigue that is not relieved by stress reduction is another required symptom for CFS diagnosis. Patients with CFS experience post-exertional malaise (PEM), which means that their symptoms worsen after physical, mental, or emotional exertion that would not have caused a problem before the illness.
Choice E is correct because severe tiredness for 2 months or more is one of the additional manifestations that must be present for CFS diagnosis. The IOM 2015 report states that the fatigue associated with CFS must last for more than 6 months and occur at least half the time at moderate, substantial or severe intensity.
Correct Answer is A
Explanation
Nonmaleficence is the ethical principle of doing no harm or preventing harm to a client. It is based on the Hippocratic oath of “primum non nocere” or “first, do no harm”. It means that the nurse should act in the best interest of the client and avoid any actions that could cause injury or suffering.
Choice B. Fidelity is the ethical principle of being faithful and loyal to a client.
It means that the nurse should keep promises, respect confidentiality, and maintain trust.
Choice C. Justice is the ethical principle of treating clients fairly and equally.
It means that the nurse should distribute resources and services based on the client’s needs and not on personal biases.
Choice D. Autonomy is the ethical principle of respecting a client’s right to make their own decisions.
It means that the nurse should inform the client of their options and support their choices, as long as they do not harm others.
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