A nurse is cheering on participants in a marathon and one runner collapses nearby. He begins to vomit and complain of a throbbing headache. The nurse notes that he is not sweating, yet his skin is red and very hot to touch, and his pulse is 170 bpm and strong. The nurse knows that:

The runner may lose consciousness due to heat stroke.

It is not necessary to call 911.

It is normal to vomit and not sweat during a marathon.

Getting the patient to a cooler, air-conditioned place will reverse the heat exhaustion.

Answer and Explanation

The Correct Answer is A

Heat stroke is a serious condition caused by overheating of the body, usually as a result of prolonged exposure to or physical exertion in high temperatures. It can damage the brain and other internal organs, and can be fatal if not treated promptly.

Some of the symptoms of heat stroke are:

• High body temperature of 104 F (40 C) or higher

• Altered mental state or behavior, such as confusion, agitation, slurred speech, seizures or coma

• Lack of sweating despite the heat

• Red, hot and dry skin

• Rapid and strong pulse

• Throbbing headach

• Nausea and vomiting

Choice B is wrong because it is necessary to call 911 if someone has heat stroke. Heat stroke is a medical emergency that requires immediate attention and cooling of the body.

Choice C is wrong because it is not normal to vomit and not sweat during a marathon. Vomiting and lack of sweating are signs of dehydration and heat stroke, which indicate that the body is unable to regulate its temperature properly.

Choice D is wrong because getting the patient to a cooler, air-conditioned place will not reverse the heat exhaustion.

Heat exhaustion is a milder form of heat-related illness that can lead to heat stroke if not treated. Heat exhaustion symptoms include heavy sweating, weakness, dizziness, nausea and muscle cramps. Getting the patient to a cooler place may help with heat exhaustion, but heat stroke requires more aggressive cooling measures such as immersing the patient in cold water or applying ice packs to the body.

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Correct Answer is D

Explanation

This is because fibromyalgia is a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues. Fibromyalgia often co-exists with other conditions, such as irritable bowel syndrome, chronic fatigue syndrome, migraine and other types of headaches. One of the main symptoms of fibromyalgia is widespread pain that has lasted for at least three months. To be considered widespread, the pain must occur on both sides of your body and above and below your waist. The pain could also be felt in specific areas called tender points. These are places on the body where even light pressure causes pain. There are 18 possible tender points on the body. Having pain in at least 11 of these points is one way to help diagnose fibromyalgia.

Choice A is wrong because chronic ocular pain related to stress, fatigue, and certain triggers is not a typical symptom of fibromyalgia.

Ocular pain is more likely to be caused by other conditions, such as dry eye syndrome, glaucoma, or eye infections.

Choice B is wrong because pain and sensitivity in the upper extremities and neck are not enough to indicate fibromyalgia. The pain must be widespread and affect both sides of the body and above and below the waist. Choice C is wrong because dull joint pain that accompanies physical exertion and which is relieved with rest is not a characteristic of fibromyalgia. The pain associated with fibromyalgia is often described as a constant dull ache that does not improve with rest. It may also be accompanied by other symptoms, such as fatigue, cognitive difficulties, and sleep problems.

A. Arterial insufficiency. B. Stasis. C. Venous insufficiency. D. Varicose veins.

Correct Answer is A

Explanation

This means that the blood flow to the affected area is reduced due to narrowed or blocked arteries. This can cause tissue death or gangrene. Diabetes can

damage the blood vessels and affect blood flow, increasing the risk of gangrene. Choice B. Stasis is wrong because it refers to a condition where blood pools in the veins of the legs, causing swelling and skin changes. It does not cause gangrene by itself.

Choice C. Venous insufficiency is wrong because it refers to a condition where the veins in the legs have problems sending blood back to the heart, causing swelling and skin ulcers. It does not cause gangrene by itself.

Choice D. Varicose veins are wrong because they are enlarged veins that may cause pain or discomfort, but do not cause gangrene by themselves.

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A nurse is cheering on participants in a marathon and one runner collapses nearby. He begins to vomit and complain of a throbbing headache. The nurse notes that he is not sweating, yet his skin is red and very hot to touch, and his pulse is 170 bpm and strong. The nurse knows that:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse identifies chronic pain as an appropriate nursing priority (or problem/diagnosis) for a client with fibromyalgia. Which manifestation did the client most likely report that caused the nurse to select this priority?

Correct Answer is D

Explanation

A diabetic client presents to the acute care facility for the amputation of two gangrenous digits on her left foot. Which type of perfusion issue has caused this condition?

Correct Answer is A

Explanation

A nurse is assessing a client who was brought to the emergency department with an ankle injury. Which of the following manifestations should the nurse identify as localized inflammation of the tissues?

While preparing a client for surgery, the nurse marks the arm that is to be amputated and participates in a “time-out” procedure before the surgery begins. Which sentinel event is this action intended to prevent?

A client is hospitalized and is in police custody after being arrested for driving while intoxicated for the third time. The nurse assigned to the client lost her brother to a drunk driver two years prior. Which action on the part of the nurse aligns with the professional code of ethics for nurses?

The RN identifies that a client is at risk for impaired skin integrity. Which interventions should the nurse add to this client’s plan of care?

Which of the following nursing diagnoses would typically NOT be associated with anemia?

Which of the following nursing diagnoses would the nurse be LEAST likely to choose for a patient with appendicitis?

A client is admitted with an exacerbation of COPD. He has a long history of chronic bronchitis. What physical finding does the nurse expect in a client with chronic bronchitis?