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
Explanation
Choice A reason:
"This test will be repeated when your baby is 2 months old. “This is a false statement. Newborn genetic screening is usually performed shortly after birth. The test is not typically repeated when the baby is 2 months old, as it is meant to detect conditions early on, allowing for prompt intervention and management if necessary.
Choice B reason:
"Your baby will be given 2 ounces of water to drink prior to the test."This is a false statement. The baby does not need to drink water before the newborn genetic screening test. The test is usually performed by collecting a small blood sample from the baby's heel, and there is no need for the baby to drink water beforehand.
Choice C reason:
"This test should be performed after your baby is 24 hours old. “This is the appropriate statement. The nurse should include the statement that newborn genetic screening should be performed after the baby is 24 hours old. Newborn genetic screening, also known as newborn screening or heel prick test, is a standard test performed on newborns to detect certain genetic, metabolic, and congenital disorders early on. The test is typically done by pricking the baby's heel to collect a small sample of blood, which is then analysed in a laboratory.
Choice D reason:
"A nurse will draw blood from your baby's inner elbow. “This is a false statement. The correct location for collecting the blood sample for newborn genetic screening is the baby's heel. The nurse will prick the baby's heel to obtain a few drops of blood, which will then be collected on a special filter paper for laboratory analysis.
Correct Answer is B
Explanation
The correct answer is choice B. Increase exercise.
Exercise can help stimulate bowel movements and prevent constipation, which is a common side effect of opioid medications.
Exercise can also improve blood circulation, reduce stress, and enhance mood, which can benefit clients who have chronic pain.
Choice A is wrong because decreasing insoluble fiber intake can worsen constipation.
Insoluble fiber adds bulk to the stool and helps it pass more easily through the colon.
Clients who take opioid medications should increase their intake of insoluble fiber from sources such as whole grains, fruits, vegetables, nuts, and seeds.
Choice C is wrong because drinking less water can lead to dehydration and hardening of the stool, which can make it more difficult to pass.
Clients who take opioid medications should drink plenty of water to keep the stool soft and moist.
Choice D is wrong because taking a laxative every day can cause dependence, tolerance, and electrolyte imbalance.
Laxatives should be used only as a last resort and under the guidance of a health care provider.
Clients who take opioid medications should try other methods of preventing constipation first, such as increasing exercise, fiber, and water intake.
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