A nurse is caring for a male client, 58 years old, in the emergency department who is suspected of having heatstroke. The primary health care provider has ordered a series of diagnostic tests and interventions. Below are the exhibits to help the nurse assess the client.
The nurse is caring for a male client suspected of having heatstroke. Which findings are consistent with this diagnosis? (Select all that apply.)
Tachycardia
Hallucinations
Skin is hot, dry
Bradycardia
Correct Answer : A,C
Choice A rationale:
Tachycardia: Heatstroke often leads to an elevated heart rate due to the body's attempt to cool down and compensate for increased body temperature. The heart rate of 120 beats per minute noted in the client is consistent with tachycardia.
Choice B rationale:
Hallucinations: While confusion and disorientation are common symptoms of heatstroke, hallucinations are not typical findings associated with heatstroke. Therefore, this is not a consistent finding for this diagnosis.
Choice C rationale:
Skin is hot, dry: One of the hallmark signs of heatstroke is hot, dry skin, which results from the body's inability to regulate its temperature effectively. The client's skin being hot to the touch and dry aligns with this characteristic.
Choice D rationale:
Bradycardia: This is characterized by a slower than normal heart rate. Since the client presents with a heart rate of 120 beats per minute, which indicates tachycardia, bradycardia is not a finding consistent with heatstroke.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Diarrhea is not a typical adverse effect of radiation treatment for breast cancer; gastrointestinal symptoms are more common with abdominal or pelvic radiation.
Choice B rationale
Anorexia, or loss of appetite, can occur but is not as common as fatigue for clients undergoing radiation treatment.
Choice C rationale
Alopecia can occur with chemotherapy, but it is less common with radiation therapy unless the radiation is directed at the scalp.
Choice D rationale
Fatigue is a common and expected adverse effect of radiation therapy due to the body's response to treatment and tissue repair processes.
Correct Answer is B
Explanation
Choice A rationale
Hyperactive deep tendon reflexes are not associated with thrombocytopenia (low platelet count). Thrombocytopenia primarily affects bleeding and clotting functions rather than neuromuscular reflexes.
Choice B rationale
Spontaneous bleeding is a significant risk with a platelet count of 9,000/mm³, which is critically low. Platelets are essential for blood clotting, and severe thrombocytopenia increases the risk of spontaneous bleeding.
Choice C rationale
Oliguria, or decreased urine output, is not directly related to thrombocytopenia. It may be associated with kidney function issues, but it is not a consequence of low platelet counts.
Choice D rationale
Infection is not directly related to a low platelet count. While patients with severe thrombocytopenia may be at risk for bleeding complications, their susceptibility to infections is more related to their white blood cell counts and immune function.
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