A nurse is caring for a client who is febrile. To reduce the client's fever, the nurse applies a cooling blanket. Which of the following findings indicates the client is having an adverse reaction to the cooling?
Tachycardia
Shivering
Flushing
Restlessness
The Correct Answer is B
A: Tachycardia might occur due to the fever itself but isn't a specific reaction to the cooling method.
B: Shivering is an adverse reaction because it indicates that the body is trying to generate heat to counteract the cooling effect of the blanket, which can increase metabolic demand and is counterproductive.
C: Flushing is typically related to fever or other causes but not directly to the adverse reaction of cooling.
D: Restlessness can be caused by discomfort or the fever itself, not specifically by cooling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. When assessing skin turgor in older adults, it is recommended to perform the test over the sternum or on the forehead. This is due to the fact that many older adults have reduced skin turgor as a part of the typical aging process, which can make it difficult to use the test to determine dehydration accurately in other areas.
B. In the elderly, skin turgor assessment on the abdomen can be influenced by factors such as adipose tissue and may not provide as reliable an indicator.
C. The shoulder is not commonly used for assessing skin turgor and may not provide reliable results.
D. The neck is not typically used for assessing skin turgor and may not provide an accurate reflection of hydration status.
Correct Answer is B
Explanation
A. Administering oral acetaminophen would not be effective for hyperthermia caused by non-infectious factors, such as heat exposure or medications. Acetaminophen lowers the body temperature by reducing the hypothalamic set point, which is not altered in hyperthermia. Additionally, oral medications may be difficult to swallow or absorb in a hyperthermic patient.
B. Hyperthermia can cause neurological complications, such as seizures, confusion, or coma. Therefore, the nurse should initiate seizure precautions for an adolescent who has hyperthermia to prevent injury and protect the airway.
C. Submerging the feet in ice water is not recommended as it can cause vasoconstriction and shivering, which may increase the body temperature. Instead, tepid sponging and providing a cool environment can be beneficial.
D. Covering the adolescent with a thermal blanket would retain body heat and exacerbate hyperthermia, counteracting efforts to lower the body temperature.
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