A nurse at an urgent care center is assisting with the care of a client who has hypothermia after exposure to frigid water. Which of the following actions should the nurse take first?

Apply a heating pad to the client's neck.

Provide the client with dry clothing.

Offer the client a warm beverage.

Wrap the client in warm blankets.

Answer and Explanation

The Correct Answer is B

A. Apply a heating pad to the client's neck: Direct application of heat to the skin, especially in localized areas like the neck, can cause rapid vasodilation, leading to a dangerous drop in blood pressure and potential cardiac complications. It also increases the risk of burns on cold-numbed skin.

B. Provide the client with dry clothing: Removing wet clothing and replacing it with dry garments is the first priority in managing hypothermia. Wet clothes accelerate heat loss through conduction and evaporation. Stopping further heat loss is essential before attempting active rewarming.

C. Offer the client a warm beverage: While offering warm fluids can help increase core temperature and provide comfort, it is not the first priority. This intervention is more appropriate after ensuring the client is dry and wrapped in warm coverings.

D. Wrap the client in warm blankets: Wrapping the client in warm blankets is a critical intervention for passive external rewarming. However, it comes after the initial step of removing wet clothes to prevent ongoing heat loss. Blankets are most effective once the source of heat loss has been eliminated.

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Correct Answer is C

Explanation

A. "The lower end of the sling goes below the client's calves." The lower end of the sling should support the thighs and buttocks but typically does not extend below the calves. Positioning the sling incorrectly can cause discomfort or injury during the lift.

B. "The sides of the sling are for the client to hold on to." While some slings have loops for the caregiver to grasp, clients usually do not hold onto the sling sides during the lift, as this could interfere with safe handling and stability.

C. "This type of device is useful for a client who cannot assist." Mechanical lifts are specifically designed to safely transfer clients who have little or no ability to assist with moving. This reduces injury risk for both client and caregiver and ensures safe mobility.

D. "The device requires the client to use upper body strength." Mechanical lifts minimize the need for client effort, especially upper body strength. They are intended for clients unable to bear weight or assist, so reliance on client strength contradicts the device’s purpose.

A. "Don't worry. Everything will work out for you." B. "We should talk about your decision later." C. "How will you discuss this decision with your loved ones?" D. "Your quality of life will be compromised if you make this decision."

Correct Answer is C

Explanation

A. "Don't worry. Everything will work out for you.": This response minimizes the client’s feelings and concerns, potentially invalidating their decision. It also avoids addressing the seriousness of the situation and does not encourage open communication or support.

B. "We should talk about your decision later.": Deferring the conversation may make the client feel ignored or unsupported. It is important to acknowledge and explore the client’s feelings and reasoning about discontinuing treatment promptly to provide appropriate care.

C. "How will you discuss this decision with your loved ones?": This response respects the client’s autonomy and opens a supportive dialogue. It encourages the client to consider communication with their support system and reflects a willingness to assist in the emotional and practical aspects of their decision.

D. "Your quality of life will be compromised if you make this decision.": This statement is judgmental and may induce guilt or fear. It does not respect the client’s right to make informed decisions about their own care and can hinder therapeutic communication.

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A nurse at an urgent care center is assisting with the care of a client who has hypothermia after exposure to frigid water. Which of the following actions should the nurse take first?

Nursing Test Bank

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A nurse at an urgent care center is assisting with the care of a client who has hypothermia after exposure to frigid water. Which of the following actions should the nurse take first?