An emergency department nurse is expecting to admit a heat stroke client en route after being found unresponsive during the hottest day of the week. Which of the following manifestations will the nurse anticipate for the client to present? (Select all that apply.)

Low urine output

Temperature lower than 97°F

No perspiration

Diaphoresis

Alert and oriented

Answer and Explanation

Correct Answer : A,C

A. Low urine output is expected in heat stroke due to significant dehydration and reduced renal perfusion. The body conserves fluids by decreasing urinary output, and acute kidney injury can develop if hypoperfusion persists, further exacerbating the risk of complications.
B. Temperature lower than 97°F would not be expected; in fact, heat stroke is characterized by hyperthermia, often with core body temperatures exceeding 104°F. A low body temperature would suggest hypothermia, not heat stroke, and thus does not align with the anticipated clinical presentation.
C. No perspiration is common in classic (non-exertional) heat stroke because the body's thermoregulatory mechanisms fail, and sweating ceases. The lack of perspiration despite extreme heat is a critical diagnostic clue that distinguishes heat stroke from milder heat-related illnesses like heat exhaustion.
D. Diaphoresis, or excessive sweating, is more typical of heat exhaustion rather than heat stroke. In heat stroke, the skin often becomes hot and dry due to the collapse of the body's cooling mechanisms, and active sweating typically stops by the time the patient becomes unresponsive.
E. Alert and oriented is unlikely in a client experiencing heat stroke severe enough to cause unresponsiveness. Heat stroke often leads to neurological dysfunction such as confusion, delirium, seizures, or coma due to direct thermal injury to brain tissues and widespread systemic effects.

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Correct Answer is A

Explanation

A. Respiratory acidosis is characterized by a low pH (below 7.35) and an elevated PaCO₂ (above 45 mm Hg), both of which are present in the client's ABG results. A respiratory rate of 7/min indicates hypoventilation, causing CO₂ retention and leading directly to respiratory acidosis. The normal bicarbonate level further confirms that the primary problem is respiratory, not metabolic.
B. Metabolic alkalosis is marked by a high pH and elevated bicarbonate levels, neither of which is present here. The client's pH is low, and the bicarbonate is within the normal range, ruling out a metabolic origin for the acid-base imbalance.
C. Respiratory alkalosis would present with a high pH and a low PaCO₂, usually caused by hyperventilation. In this case, the client is hypoventilating, with high CO₂ and low pH values, which is the opposite pattern seen in respiratory alkalosis.
D. Metabolic acidosis involves a low pH accompanied by a decreased bicarbonate level, typically less than 22 mEq/L. Since the client's bicarbonate is normal at 26 mEq/L and the PaCO₂ is elevated, the acid-base disturbance is respiratory rather than metabolic.

A. A client who has severe respiratory stridor and a deviated trachea B. A client who has a small circular partial thickness burn of the left calf C. A client who has a massive head injury and is experiencing seizures D. A client who has a splinted open fracture of left medial malleolus

Correct Answer is A

Explanation

A. A client who has severe respiratory stridor and a deviated trachea must be assessed first because this indicates a life-threatening airway obstruction, possibly from a tension pneumothorax. Immediate intervention is required to secure the airway and prevent complete respiratory failure and death.
B. A client who has a small circular partial thickness burn of the left calf is stable and can be safely delayed for later treatment. Partial-thickness burns on a small area of the body do not pose an immediate threat to life or limb.
C. A client who has a massive head injury and is experiencing seizures is critical, but massive head trauma with ongoing seizures often has a poor prognosis, and during a mass casualty event, resources are prioritized for those with the best chances of survival with intervention.
D. A client who has a splinted open fracture of the left medial malleolus is stable after splinting and does not require immediate life-saving measures. Orthopedic injuries without severe bleeding can generally wait for definitive treatment.

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An emergency department nurse is expecting to admit a heat stroke client en route after being found unresponsive during the hottest day of the week. Which of the following manifestations will the nurse anticipate for the client to present? (Select all that apply.)

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Correct Answer is A

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