On a hot humid day, a nurse is caring for a client who is confused and presents with these vital signs: temperature 104.1°F (40.1°C), pulse 132 beats/min, respirations 26 breaths/min, and blood pressure 106/66 mmHg.
What action would the nurse take to provide immediate appropriate care?
Encourage the client to drink cool water or sports drinks.
Administer acetaminophen 650 mg orally.
Start an intravenous line and infuse 0.9% saline solution.
Encourage rest and reassess in 15 minutes.
The Correct Answer is C
Choice A rationale
Encouraging the client to drink cool water or sports drinks is appropriate for mild dehydration or heat exhaustion but not sufficient for severe heat-related illness like heat stroke, where immediate medical intervention is needed.
Choice B rationale
Administering acetaminophen 650 mg orally can help reduce fever, but it does not address the underlying issue of hyperthermia and will not provide immediate cooling needed in this emergency.
Choice C rationale
Starting an intravenous line and infusing 0.9% saline solution helps rapidly replace fluids lost through sweating and can stabilize the client's condition by rehydrating and cooling them effectively.
Choice D rationale
Encouraging rest and reassessing in 15 minutes would delay necessary medical treatment in a situation where immediate action is critical due to the severity of the client's symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C"]
Explanation
Choice A rationale:
Tachycardia: Heatstroke often leads to an elevated heart rate due to the body's attempt to cool down and compensate for increased body temperature. The heart rate of 120 beats per minute noted in the client is consistent with tachycardia.
Choice B rationale:
Hallucinations: While confusion and disorientation are common symptoms of heatstroke, hallucinations are not typical findings associated with heatstroke. Therefore, this is not a consistent finding for this diagnosis.
Choice C rationale:
Skin is hot, dry: One of the hallmark signs of heatstroke is hot, dry skin, which results from the body's inability to regulate its temperature effectively. The client's skin being hot to the touch and dry aligns with this characteristic.
Choice D rationale:
Bradycardia: This is characterized by a slower than normal heart rate. Since the client presents with a heart rate of 120 beats per minute, which indicates tachycardia, bradycardia is not a finding consistent with heatstroke.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
Systemic lupus erythematosus often causes photosensitivity, which is an increased sensitivity to sunlight, leading to skin rashes and other reactions. Additionally, chronic fatigue is a common symptom in individuals with SLE, as described by the progressive fatigue that the client has been experiencing. Weight loss and hypoglycemia are not directly related to the common complications of SLE mentioned in the exhibits.
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