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 C

Explanation

Choice A rationale
Examining the client for hepatomegaly can be part of a broader assessment but does not directly address the fatigue related to chemotherapy, particularly cisplatin, which is known to cause bone marrow suppression.
Choice B rationale
Assessing for a hypersensitivity reaction is important during chemotherapy, but it does not specifically address the issue of fatigue, which is often related to blood cell counts.
Choice C rationale
Checking the results of the client's most recent CBC (complete blood count) is crucial because cisplatin can cause anemia, leukopenia, and thrombocytopenia, all of which can lead to significant fatigue.
Choice D rationale
Evaluating for hypercalcemia is not typically associated with cisplatin treatment; it is more relevant in malignancies associated with bone metastasis or overproduction of parathyroid hormone-related protein.

A. A child who has rheumatic fever. B. A child recovering from a ruptured appendix. C. A child who has cystic fibrosis. D. A child who has nephrotic syndrome.

Correct Answer is D

Explanation

Choice A rationale
A child with rheumatic fever could carry infectious agents that might pose a risk to a child with severe immunocompromise such as low WBC.
Choice B rationale
A child recovering from a ruptured appendix might have residual infection or be at higher risk of infection, which could be dangerous for a child with very low WBC count.
Choice C rationale
A child with cystic fibrosis has a risk of respiratory infections, posing a threat to a child with a compromised immune system like severe neutropenia.
Choice D rationale
A child with nephrotic syndrome does not typically carry infectious risks and would be a safer roommate for a child with a compromised immune system due to low WBC count.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving cisplatin to treat bladder cancer. After several treatments, the client reports fatigue. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is admitting a child who has a total WBC count of 1200. Which of the following clients should the nurse place in the same room with this child?

Correct Answer is D

Explanation

A nurse is caring for a client who has nausea and a prescription for metoclopramide intermittent IV bolus every 4 hours as needed. The client asks the nurse how metoclopramide will relieve her nausea. Which of the following explanations should the nurse provide?

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?

A nurse is reviewing the CBC findings for a female client who is receiving combination chemotherapy for breast cancer. Which of the following findings should the nurse report to the provider?

A nurse is teaching a client who has stage IV pancreatic cancer about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?

A nurse is planning care for a client who is being treated with chemotherapy and radiation for metastatic breast cancer, and who has neutropenia. The nurse should include which of the following restrictions in the client's plan of care?

A female middle adult client tells a nurse that she tested positive for a mutant BRCA1 gene. The nurse should recognize that the client is at an increased risk for which of the following situations?

A nurse is preparing a client who is to receive chemotherapy for treatment of ovarian cancer.Which of the following actions should the nurse plan to take?

A nurse is creating the plan of care for a client who is immunosuppressed.Which of the following precautions should the nurse include in the plan? (Select all that apply)