A nurse is preparing to admit a 6-year-old with varicella to the pediatric unit.

Which of the following actions should the nurse take?

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).

Answer is B, C, D, E, F. These are the findings that suggest possible elder abuse or neglect.

• B: Client’s report of lack of food in home. This may indicate neglect by the adult child who is supposed to provide adequate nutrition for the client.
• C: Client’s report of lack of access to bank accounts. This may indicate financial abuse by the adult child who is controlling the client’s money without his permission.
• D: Client’s avoidance of eye contact. This may indicate emotional abuse by the adult child who is intimidating or threatening the client.
• E: Client’s report of weight loss. This may indicate neglect by the adult child who is not meeting the client’s basic needs or physical abuse by the adult child who is causing bodily harm to the client.
• F: Numerous bruises in various stages of healing. This may indicate physical abuse by the adult child who is hitting or injuring the client.

A: ECG results. This is not a finding that suggests elder abuse or neglect. It is a diagnostic test that measures the electrical activity of the heart and can help detect cardiac problems. It does not provide information about the client’s social or emotional well-being.

Normal ranges for vital signs:.

• Temperature: 36.1°C to 37.2°C (97°F to 99°F).
• Heart rate: 60 to 100 beats per minute.
• Blood pressure: less than 120/80 mm Hg.
• Respiratory rate: 12 to 20 breaths per minute.
• SpO2: 95% to 100% on room air. Table for BMI categories:

The client’s BMI is 18.3, which indicates he is underweight and may be malnourished or have a medical condition that causes weight loss.