A nurse is assessing a client who has hypothermia. Which of the following findings should the nurse identify as a manifestation of hypothermia?
Impaired coordination
Sensitivity to light
Increased respiratory rate
Hypertension
The Correct Answer is A
A) Impaired coordination:
Impaired coordination is a common manifestation of hypothermia. As the body temperature drops, the nervous system is affected, leading to difficulties in motor control and coordination. This symptom is indicative of the body's struggle to maintain normal physiological functions in response to the cold.
B) Sensitivity to light:
Sensitivity to light is not typically associated with hypothermia. This symptom is more commonly related to conditions affecting the eyes or the central nervous system, such as migraines or meningitis.
C) Increased respiratory rate:
Hypothermia generally leads to a decreased respiratory rate as the body's metabolic processes slow down. An increased respiratory rate is not a common symptom and may indicate another underlying condition or a compensatory mechanism for another issue.
D) Hypertension:
Hypertension is not a typical manifestation of hypothermia. In fact, as hypothermia progresses, the body's blood pressure often decreases due to reduced cardiac output and peripheral vasoconstriction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) "Sit with your legs in a dependent position when in a chair."
Sitting with legs in a dependent position can decrease blood flow and increase the risk of clot formation. It's important to elevate the legs when sitting to promote venous return and reduce the risk of deep-vein thrombosis (DVT).
B) "Prevent dehydration by drinking at least 2.5 liters fluids each day."
Staying well-hydrated helps maintain good blood circulation and prevents blood from becoming too viscous, reducing the risk of clot formation. Adequate fluid intake is crucial in preventing DVT.
C) "Massage your calves after sitting for 2 hours."
Massaging the calves is not recommended for someone with a history of DVT, as it may dislodge a clot. Instead, clients should be encouraged to move or stretch their legs regularly to improve circulation.
D) "Roll stretchy nylon stockings down to the upper part of your calves."
Proper use of compression stockings involves wearing them as prescribed, which typically means keeping them fully extended to ensure consistent pressure along the leg. Rolling them down can create a tourniquet effect and is not recommended.
Correct Answer is A
Explanation
A) Orthostatic hypotension: Anemia often results in decreased blood volume and oxygen-carrying capacity, which can cause orthostatic hypotension. This condition is characterized by a sudden drop in blood pressure when moving from a sitting or lying position to standing, leading to dizziness or fainting.
B) Clubbing of the nail beds: Clubbing is typically associated with chronic hypoxia and long-term respiratory or cardiovascular diseases, rather than anemia. It involves the enlargement of the fingertips and changes in the angle of the nail bed.
C) Conjunctivitis: Conjunctivitis is an inflammation of the conjunctiva, usually caused by infections, allergies, or irritants. It is not a common manifestation of anemia.
D) Heat intolerance: Heat intolerance is more commonly associated with hyperthyroidism or other metabolic disorders rather than anemia. Individuals with anemia are more likely to experience cold intolerance due to reduced oxygen delivery to tissues.
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