A client presents to the emergency department following an extended period outside in colder temperatures. The client's rectal temperature is 92 degrees F. Based on this finding, what clinical manifestations would the nurse anticipate? Select all that apply:
Cool skin
Bradycardia
Impaired muscle coordination
Flushed skin
Diminished pain sensation
Tachycardia
Irregular heart rhythm
Listlessness
Impaired cognition
Correct Answer : A,B,C,E,G,H,I
A. Cool skin: Hypothermia causes decreased skin temperature and pallor/cold skin on exposure.
B. Bradycardia: As core temperature falls, cardiac conduction slows and bradycardia commonly develops.
C. Impaired muscle coordination: Hypothermia slows nerve conduction and muscle function, causing clumsiness and decreased coordination.
D. Flushed skin: Flushed, warm skin is associated with hyperthermia or vasodilation; hypothermia typically produces cool, pale or cyanotic skin.
E. Diminished pain sensation: Cold reduces nerve conduction and sensation, often causing numbness and decreased pain perception.
F. Tachycardia: Tachycardia is more typical in early/mild stress responses; at moderate hypothermia (≈92°F) bradycardia is expected rather than tachycardia.
G. Irregular heart rhythm: Hypothermia predisposes to arrhythmias (e.g., atrial fibrillation, other irregular rhythms).
H. Listlessness: Mental slowing, lethargy, and decreased responsiveness commonly occur with significant hypothermia.
I. Impaired cognition: Cognitive impairment, confusion, and slowed mentation are common as core temperature drops.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Gauze pads: Gauze dressings are absorbent, can be layered or packed to manage moderate to heavy exudate, and are commonly used when high absorbency is needed.
B. Transparent dressing: Transparent (occlusive) dressings allow visualization and are for minimal exudate or to cover IV sites; they are not highly absorbent.
C. Hydrocolloid dressing: Hydrocolloid dressings absorb light to moderate exudate and promote moist healing but are not the most absorbent option for moderately heavy drainage.
D. Ace wrap: An ACE wrap is an elastic bandage used for compression/support, not for absorbing wound exudate.
Correct Answer is D
Explanation
A. Due to increase in physical activity: Increased activity tends to raise body temperature; older adults typically have lower activity levels, so this does not explain a lower baseline temperature.
B. Increase in subcutaneous body fat and metabolic rate: Increased subcutaneous fat and metabolic rate would tend to conserve heat and raise temperature; aging is associated with the opposite change.
C. Due to an increase in protein intake in their diet: Dietary protein does not directly cause a lower core body temperature in older adults.
D. Decrease in subcutaneous body fat and metabolic rate: Age-related loss of subcutaneous fat and a lower metabolic rate reduce heat production and insulation, contributing to a tendency toward lower body temperature.
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