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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A) Place the client in a semi-Fowler's position:
While positioning can be beneficial for various conditions, it does not directly address the core issue of hypothermia. Rewarming the client effectively is the primary concern in hypothermia management.

B) Infuse warm IV fluids:
Administering warm IV fluids is a crucial intervention for moderate hypothermia as it helps increase the client's core body temperature more rapidly and effectively. This method ensures that the body's internal temperature is raised, which is vital for stabilizing the client.

C) Assess the client's skin hourly when using a heating blanket:
Monitoring the skin is important to prevent burns or skin damage from a heating blanket, but it is a supportive measure rather than a primary intervention. The key priority is to rewarm the client’s core.

D) Rewarm the client's extremities first:
Rewarming the extremities first can actually be harmful in hypothermia, as it can lead to a drop in core body temperature due to the return of cold blood from the periphery to the core (afterdrop). The focus should be on warming the core body first.

A. "Use petroleum jelly on a cotton ball to plug your ear when shampooing." B. "Clean dried blood in your ear canal with a cotton-tipped applicator." C. "Avoid blowing your nose for 1 month after surgery." D. "Notify your provider if you have popping or crackling sensations in the affected ear."

Correct Answer is C

Explanation

A) Use petroleum jelly on a cotton ball to plug your ear when shampooing.
This technique helps prevent water from entering the ear during activities like showering. While it is useful for keeping the ear dry, it does not directly address preventing trauma or further hearing impairment post-surgery.

B) Clean dried blood in your ear canal with a cotton-tipped applicator.
Using cotton-tipped applicators can cause damage to the delicate ear canal and potentially disturb the surgical site. This action increases the risk of infection and trauma, potentially worsening hearing loss instead of preventing it.

C) Avoid blowing your nose for 1 month after surgery.
Refraining from nose blowing is essential because it prevents pressure changes that could disrupt the surgical repair. Such pressure changes can lead to complications like graft displacement, which can cause trauma and impair hearing.

D) Notify your provider if you have popping or crackling sensations in the affected ear.
Popping or crackling can be common as the ear heals and adjusts. These sensations typically do not indicate a problem unless accompanied by pain or other symptoms. Thus, while monitoring is important, it is not a primary preventative measure for trauma or hearing issues.

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A nurse is assessing a client who has hypothermia. Which of the following findings should the nurse identify as a manifestation of hypothermia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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