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
Fluid volume excess is wrong because appendicitis does not cause fluid retention or overload. It may cause fluid loss due to vomiting, fever, or rupture of the appendix. Therefore, a more appropriate nursing diagnosis would be the risk for deficient fluid volume.
Choice B. Risk for infection is correct because appendicitis is an inflammatory condition that can lead to bacterial infection, especially if the appendix ruptures and causes peritonitis or abscess formation.
Choice C. Ineffective thermoregulation is correct because appendicitis can cause fever due to inflammation and infection.
Choice D. Pain is correct because appendicitis causes acute abdominal pain that usually starts in the periumbilical area and then localizes to the right lower quadrant. The pain may be accompanied by nausea, vomiting, and rebound tenderness.
Correct Answer is D
Explanation
A client with chronic bronchitis is expected to have a cough that produces sputum for at least 3 months during two successive years. This is due to the hyperplasia of mucous glands and bronchial wall inflammation that occur in chronic bronchitis.
Choice A is wrong because SpO2 >92% is not a specific finding for chronic bronchitis.
SpO2 is a measure of oxygen saturation in the blood and can vary depending on many factors, such as altitude, smoking, and lung diseases. SpO2 may be lower than normal in COPD patients due to airflow obstruction and impaired gas exchange.
Choice B is wrong because underweight is not a typical finding for chronic bronchitis.
Underweight may be more associated with emphysema, which is another component of COPD that involves the destruction of alveolar walls and enlargement of air spaces. Emphysema can cause weight loss due to increased work of breathing and decreased appetite.
Choice C is wrong because bradypnea is not a common finding for chronic bronchitis.
Bradypnea is abnormally slow breathing rate and can be caused by various conditions, such as brain injury, drug overdose, or sleep apnea. Chronic bronchitis usually causes tachypnea, which is abnormally fast breathing rate, due to hypoxia and hypercapnia.
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