The nurse is caring for a patient who came to the emergency department with confusion and muscle cramps after working outside on a hot day. What is the priority action of the nurse?
Remove fans to prevent premature chilling.
Apply a hyperthermia blanket to lower temperature slowly.
Take the patient's temperature and vital signs.
Place the patient in a tub of iced water.
The Correct Answer is C
A. Remove fans to prevent premature chilling. While preventing rapid cooling is important in some cases, this action is not the priority. The patient’s symptoms suggest heat-related illness, which requires immediate assessment.
B. Apply a hyperthermia blanket to lower temperature slowly. Hyperthermia blankets are typically used in controlled environments for gradual cooling, but first, the patient’s temperature must be assessed to determine the severity of heat-related illness.
C. Take the patient's temperature and vital signs. Confusion and muscle cramps after working in heat suggest possible heat exhaustion or heatstroke, which can be life-threatening. Assessing temperature and vital signs is the priority to determine the severity and guide further treatment.
D. Place the patient in a tub of iced water. Ice water immersion is appropriate for severe heatstroke with a dangerously high core temperature, but cooling measures should only be initiated after confirming hyperthermia with a temperature assessment.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Due to a specific stimulus. Pain can occur with or without an identifiable stimulus. Conditions like neuropathic pain or phantom limb pain exist without an obvious external cause.
B. Caused by a single physiological situation. Pain can result from multiple factors, including tissue damage, nerve dysfunction, inflammation, and psychological influences. It is not limited to one specific physiological cause.
C. Universally the same for everyone. Pain perception varies widely between individuals due to differences in pain tolerance, cultural background, past experiences, and psychological state.
D. Subjective. Pain is defined as whatever the patient says it is, making it a subjective experience. It cannot be measured objectively, and the best indicator of pain is the patient’s self-report.
Correct Answer is C
Explanation
A. Hyperventilation. Opioid overdose depresses the central nervous system, leading to slow and shallow breathing, not increased respiratory rate (hyperventilation).
B. Eupnea. Eupnea refers to normal breathing, which is unlikely in opioid overdose because opioids suppress respiratory drive.
C. Bradypnea. Opioids act on the brainstem's respiratory centers, leading to respiratory depression, characterized by slow breathing (bradypnea) and, in severe cases, respiratory arrest. This is the most life-threatening effect requiring immediate intervention.
D. Hyperpnea. Hyperpnea refers to deep breathing, which is not a typical response to opioid overdose. Instead, breathing becomes slow and shallow, increasing the risk of hypoxia.
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