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.

Exhibits

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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale
Avoiding crowds is to prevent the client from getting infections due to immunosuppression, not to prevent spreading infection to others, thus an incorrect rationale.
Choice B rationale:
Running a toothbrush through a dishwasher may seem hygienic but is generally unnecessary. More effective measures are needed to ensure oral hygiene without excessive sterilization.
Choice C rationale
Antiemetics are typically taken prior to or at the first sign of nausea during chemotherapy, not after the infusion is complete, so this statement is incorrect regarding the timing of antiemetic use.
Choice D rationale
Calling the doctor for unusual menstrual bleeding is crucial as it can indicate thrombocytopenia, a potential side effect of chemotherapy, reflecting the client's correct understanding.

A. Apply powder liberally to sensitive skin areas. B. Wash the hair with a strong protein shampoo. C. Use a sun-blocking agent with a sun protection factor of at least 30. D. Avoid using moisturizing lotions on the skin.

Correct Answer is C

Explanation

Choice A rationale
Applying powder to sensitive skin areas can cause dryness and irritation, exacerbating SLE symptoms. Powders can also block pores, increasing the risk of skin infections.
Choice B rationale
Using a strong protein shampoo is not relevant to managing SLE. It won't address the photosensitivity or skin issues commonly associated with SLE.
Choice C rationale
Sun protection is crucial for SLE patients due to photosensitivity. UV exposure can trigger flare-ups, making a sun-blocking agent with SPF 30 or higher essential for skin protection.
Choice D rationale
Moisturizing lotions help prevent dryness and protect the skin barrier, which is important in SLE management. Avoiding them can lead to skin complications.

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Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has breast cancer about the adverse effects of chemotherapy. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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