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 B
Explanation
A. Provide 60 mL (2 oz) of fluid intake every 5 min. Immediately post-surgery, fluid intake is usually more restricted and administered in smaller, more controlled quantities to prevent strain on the surgical site.
B. After gastric bypass surgery, monitoring for signs of complications such as leaks, obstructions, or internal bleeding is crucial. Measuring abdominal girth daily is not typically necessary unless specific complications are suspected.
C. Introducing a soft diet immediately post-surgery is typically delayed to allow healing; patients usually start with clear liquids.
D. Early ambulation is generally encouraged postoperatively to prevent complications like deep vein thrombosis and to promote gastrointestinal function, often starting as soon as the first postoperative day.
Correct Answer is C
Explanation
A. Having social support from friends is a protective factor against child abuse.
B. Seeking support from other parents indicates a healthy coping mechanism and reduces the risk of child abuse.
C. This statement suggests unrealistic expectations about the baby's development and behavior, which could lead to frustration and increased risk of child abuse. Unrealistic expectations are a risk factor for abusive behavior towards children.
D. This statement reflects attentiveness and responsiveness to the baby's needs, which reduces the risk of child abuse.
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