A nurse is caring for an adolescent who has hyperthermia.
Which of the following actions should the nurse take?
Cover the adolescent with a thermal blanket
Submerge the adolescent’s feet in ice water
Initiate seizure precautions
Administer oral acetaminophen
The Correct Answer is C
Hyperthermia is a condition in which the body temperature is abnormally high, usually due to exposure to heat, infection, or certain medications.
Hyperthermia can cause neurological complications, such as seizures, confusion, or coma. Therefore, the nurse should initiate seizure precautions for an adolescent who has hyperthermia to prevent injury and protect the airway.
Choice A is wrong because covering the adolescent with a thermal blanket would increase the body temperature and worsen hyperthermia. The nurse should remove excess clothing and use cooling measures, such as fans, ice packs, or cool fluids.
Choice B is wrong because submerging the adolescent’s feet in ice water would cause vasoconstriction and shivering, which would reduce heat loss and increase heat production. The nurse should avoid using extreme cold or ice water to cool the body.
Choice D is wrong because administering oral acetaminophen would not be effective for hyperthermia caused by non-infectious factors, such as heat exposure or medications.
Acetaminophen lowers the body temperature by reducing the hypothalamic set point, which is not altered in hyperthermia. Additionally, oral medications may be difficult to swallow or absorb in a hyperthermic patient.
Normal body temperature ranges from 36.5°C to 37.5°C (97.7°F to 99.5°F). Hyperthermia is defined as a body temperature above 38.5°C (101.3°F).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
The correct answer is choice CDE.
Choice A rationale:
Eating fish for dinner at least twice per week is not specifically recommended for pancreatitis patients. A low-fat diet is generally advised, but the frequency of fish consumption is not a key point in discharge teaching.
Choice B rationale:
Limiting coffee intake is not a primary focus in pancreatitis discharge instructions. While caffeine can irritate the digestive system, the emphasis is more on avoiding alcohol and fatty foods.
Choice C rationale:
Eating small, frequent meals is recommended to avoid overloading the digestive system and to help manage symptoms of pancreatitis.
Choice D rationale:
Pale bowel movements can indicate a problem with bile flow, which is not a normal expectation for pancreatitis patients. This could suggest a complication that needs medical attention.
Choice E rationale:
Dark urine can be a sign of dehydration or liver issues, which should be reported to a healthcare provider as it may indicate a complication.
Correct Answer is B
Explanation
Choice A reason:
Explaining the procedure to the client before verifying informed consent is not an appropriate action: While it is essential to explain the procedure to the client and ensure they have a clear understanding of what they are consenting to, this step typically occurs before the informed consent form is presented. The purpose of the informed consent form is to document that the client has received adequate information and has given their consent voluntarily
Choice B reason:
Confirming the client's signature is authentic is the correct action. Verifying the record of informed consent for a client scheduled for surgery involves several important steps. Of these, the nurse's primary responsibility is to ensure that the client's signature on the informed consent form is authentic. This means ensuring that the client themselves or their authorized representative has signed the form willingly and without coercion.
Choice C reason:
Providing information on the informed consent form about the benefits of the surgery is not an appropriate action: The informed consent form typically contains information about the procedure, its risks, possible complications, and alternatives, but it is not the nurse's responsibility to provide this information. The healthcare provider or surgeon is responsible for explaining the details of the surgery to the client before obtaining their consent.
Choice D reason:
Informing the client about the condition that requires treatment is not an appropriate action: The responsibility of informing the client about their medical condition, the need for treatment, and the available options lies with the healthcare provider or surgeon, not the nurse. The nurse may assist in providing information or answering questions, but the primary responsibility for discussing the medical condition lies with the provider.
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