A nurse is reinforcing teaching with a group of older adult clients about preventing hypothermia in the winter.Which of the following information should the nurse include in the teaching?

Set the indoor temperature at 17°C (64°F).

Eat low-carbohydrate meals and snacks.

Cover the head when sleeping at night.

Wear a single layer of warm clothing.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Setting the indoor temperature at 17°C (64°F) is too low for older adults, increasing their risk for hypothermia. A higher indoor temperature is recommended for safety.

Choice B rationale

Low-carbohydrate diets are not ideal in preventing hypothermia. Carbohydrates are essential for energy production and thermoregulation, especially in colder weather.

Choice C rationale

Covering the head is critical as significant heat loss occurs through the head. This practice helps conserve body heat during colder temperatures.

Choice D rationale

Wearing a single layer is insufficient for retaining body heat in winter. Layering clothing provides insulation by trapping warm air, which helps prevent hypothermia. .

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Correct Answer is A

Explanation

Choice A rationale

Wet clothing exacerbates hypothermia by promoting heat loss through convection and evaporation. Replacing them with warmed blankets initiates passive rewarming, critical to restore normal body temperature (36.5°C to 37.5°C). Maintaining a warm environment minimizes shivering-induced metabolic demands and improves thermal regulation post-rescue.

Choice B rationale

Axillary thermometers measure skin temperature, often inaccurate in hypothermia where core temperature is needed. Core measurements via rectal or esophageal probes provide reliable readings, guiding rewarming interventions and severity classification, crucial for life-threatening hypothermia management.

Choice C rationale

Antihypertensives lower blood pressure and are inappropriate in hypothermia-related bradycardia or hypotension. Hypothermia-induced vasoconstriction maintains critical perfusion; medication interruption can worsen cardiovascular instability and reduce survival chances. Warmth stabilization precedes pharmacological actions.

Choice D rationale

Range-of-motion exercises increase metabolic rate but are not appropriate during hypothermia recovery. Muscular activity elevates oxygen demand, aggravating hypothermia risks such as arrhythmias. Passive warming supersedes these efforts until the client reaches normothermia and stability.

A. The client should wear a mask during transport. B. The nurse should wear a mask during transport. C. The client should wear a gown during transport. D. The nurse should wear a gown during transport.

Correct Answer is A

Explanation

Choice A rationale

The client wearing a mask during transport helps minimize the risk of transmitting infectious droplets to others. It is the most effective precaution to uphold droplet isolation protocols and ensure safe transport in healthcare settings.

Choice B rationale

The nurse wearing a mask is standard PPE practice, but it does not address the primary goal of preventing the client from spreading infectious droplets during transportation. The client must be the primary focus of this preventive measure.

Choice C rationale

Wearing a gown is unnecessary for droplet precautions during transport. Droplet isolation measures primarily target respiratory secretions, and gowns are not effective for minimizing respiratory droplet dissemination.

Choice D rationale

Similar to Choice C, the nurse wearing a gown is not a droplet precaution strategy related to transportation. The focus remains on respiratory measures, specifically masking the client.

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A nurse is reinforcing teaching with a group of older adult clients about preventing hypothermia in the winter.Which of the following information should the nurse include in the teaching?

Nursing Test Bank

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