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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A: Placing the bedside table at the foot of the bed may not directly reduce the risk of injury for a client with dementia.
B: Assisting the client to the toilet frequently can prevent falls and accidents associated with incontinence, which are common concerns for clients with dementia.
C: Raising the side rails up can potentially increase the risk of injury if the client attempts to climb over them, leading to falls or entrapment.
D: Keeping the television on during the night may not directly address the risk of injury for the client.

A. Provide a cooling blanket. B. Monitor the client's cardiac rhythm. C. Administer 0.9% sodium chloride IV. D. Obtain the client's blood glucose.

Correct Answer is B

Explanation

A. While a cooling blanket may be indicated to reduce fever associated with a thyroid storm, the priority lies in monitoring the cardiac rhythm for potential life-threatening complications such as tachycardia or arrhythmias.
B. Thyroid storm can precipitate severe cardiac complications, making continuous monitoring of the client's cardiac rhythm imperative to detect any abnormalities promptly.
C. Administering IV fluids may be necessary to address dehydration, but it is not the priority over monitoring the cardiac rhythm.
D. While monitoring blood glucose levels is important, it is not the immediate priority in managing a thyroid storm.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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