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 C
Explanation
A) Hispanic ethnicity: While ethnicity can influence the prevalence and risk of hypertension, Hispanic ethnicity alone is not a direct risk factor for hypertension. Other factors such as lifestyle, diet, and genetic predispositions play more significant roles in the development of hypertension.
B) Cholesterol 190 mg/dL: Although elevated cholesterol levels can contribute to cardiovascular disease, a cholesterol level of 190 mg/dL is considered borderline high but not a primary risk factor for hypertension. The risk for hypertension is more directly related to factors like blood pressure levels and weight.
C) BMI of 28: A Body Mass Index (BMI) of 28 falls into the overweight category, which is a known risk factor for developing hypertension. Excess body weight can increase blood pressure by increasing the workload on the heart and contributing to insulin resistance, which can further elevate blood pressure.
D) History of atrial fibrillation: While atrial fibrillation is a significant cardiac condition and can be associated with other cardiovascular risks, it is not a direct risk factor for the development of hypertension. The primary risk factors for hypertension include factors like obesity, diet, and physical inactivity.
Correct Answer is D
Explanation
A) Double-bag the client's trash before removing it from the room: Double-bagging trash is typically recommended for patients with highly contagious and severe infectious diseases, such as those requiring contact precautions. Influenza, while contagious, does not necessitate this level of precaution.
B) Place the client in a negative air pressure room with 6 to 12 air exchanges per hour: Negative air pressure rooms are used for airborne diseases like tuberculosis or measles, which can spread through the air over long distances. Influenza primarily spreads through respiratory droplets, so this precaution is not necessary.
C) Ensure all air in the client's room is filtered through a HEPA filter: HEPA filters are used for airborne pathogens to filter out infectious particles. Since influenza spreads via respiratory droplets rather than airborne particles, this level of air filtration is not required.
D) Wear a surgical mask when within 1 m (3 ft) of the client: Influenza spreads through respiratory droplets, which can travel up to about 1 meter (3 feet) when a person coughs or sneezes. Wearing a surgical mask within this distance helps prevent inhalation of these droplets, making it the appropriate precaution for influenza.
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