Which patient assessment data does the nurse recognize could contribute to an older adult's risk of hyperthermia?
Keeps room temperature at 72°F
Has a history of osteoarthritis
Takes furosemide 40 mg daily
Bathes daily with a hot shower
The Correct Answer is C
A. Keeps room temperature at 72°F.
Explanation: Maintaining a room temperature of 72°F is generally considered comfortable and is not likely to contribute to hyperthermia, especially when compared to higher temperatures. However, it's essential to consider individual preferences and comfort levels.
B. Has a history of osteoarthritis.
Explanation: Osteoarthritis itself is not directly associated with an increased risk of hyperthermia. However, limitations in mobility or difficulties with self-care due to osteoarthritis might indirectly impact the ability to stay cool and hydrated, so comprehensive care should consider the overall health status of the individual.
C. Takes furosemide 40 mg daily.
Explanation: Furosemide is a diuretic that increases urine production, leading to fluid loss. Dehydration or electrolyte imbalances resulting from diuretic use can contribute to an increased risk of hyperthermia, especially in hot weather. It's important for healthcare providers to monitor and manage medications, considering their potential effects on fluid balance and thermoregulation.
D. Bathes daily with a hot shower.
Explanation: While taking hot showers may contribute to temporary elevation of body temperature, bathing alone may not be a significant contributor to hyperthermia. However, if an older adult has difficulty tolerating heat or maintaining hydration, it's essential to consider the cumulative impact of various factors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Defecation less than once each day is not necessarily constipation.
Explanation: The frequency of bowel movements varies among individuals, and defecating less than once each day does not necessarily indicate constipation. Normal bowel habits can differ, and what is considered regular for one person may not be the same for another. Constipation is better assessed by considering other factors such as stool consistency, straining during bowel movements, and feelings of incomplete evacuation.
B. Leaking liquid feces should be treated as diarrhea.
Explanation: Leaking liquid feces may be indicative of diarrhea, but it is not the only factor to consider. The cause of diarrhea should be investigated, and treatment will depend on the underlying reason, which may include infections, medications, or other medical conditions.
C. Mineral oil is recommended as a laxative for the older adult.
Explanation: Mineral oil is generally not recommended as a laxative for older adults. It can interfere with the absorption of fat-soluble vitamins and may have adverse effects. There are other safer and more effective laxative options that healthcare providers may recommend.
D. Excessive sleep can be a symptom of constipation.
Explanation: Excessive sleep is not typically considered a symptom of constipation. Constipation is more commonly associated with symptoms such as infrequent bowel movements, difficulty passing stool, and abdominal discomfort. Sleep disturbances may have various causes, but they are not a direct symptom of constipation.
Correct Answer is A
Explanation
A. Ensuring ready access to a toilet or commode.
Explanation: Ensuring ready access to a toilet or commode for the client is a practical measure to address bowel incontinence. This proactive approach allows the client to respond to the urge to defecate promptly, reducing the risk of incontinence episodes.
B. Encouraging the intake of 1 L of water each day.
Explanation: While maintaining adequate hydration is important for overall bowel health, it may not directly address the issue of bowel incontinence.
C. Expecting a rapid and full recovery.
Explanation: The expectation of rapid and full recovery does not constitute a specific intervention for addressing bowel incontinence. The approach to managing bowel incontinence is typically individualized and may involve various strategies depending on the underlying causes.
D. Toileting the client 10 to 15 minutes after meals.
Explanation: Toileting the client after meals is a timing strategy that may help take advantage of the gastrocolic reflex, but it is only one aspect of a comprehensive program for managing bowel incontinence. Other interventions, such as dietary adjustments, exercise, and toileting schedules, may also be considered based on the client's specific needs.
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