During an assessment of a client exposed to cold temperatures, which finding would the nurse recognize as an early manifestation of hypothermia?
Bradycardia
Decreased level of consciousness
Shivering
Hypotension
The Correct Answer is C
Rationale:
A. Bradycardia is typically a later sign of moderate to severe hypothermia, as the body’s core temperature drops significantly. Early hypothermia usually triggers compensatory mechanisms rather than slowing the heart rate.
B. Altered mental status occurs later in hypothermia when core body temperature falls substantially. Early stages are usually accompanied by alertness, as the body attempts to generate heat.
C. Shivering is the primary early physiological response to cold exposure. It is the body’s mechanism to generate heat through involuntary muscle activity and typically occurs when core body temperature begins to drop slightly below normal (mild hypothermia, 35–36°C or 95–96.8°F). Shivering is an important warning sign that the body is losing heat and compensating to maintain homeostasis.
D. Hypotension is a later manifestation of hypothermia due to cardiovascular depression and vasoconstriction failure. Early hypothermia usually presents with peripheral vasoconstriction, not low blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Asking the patient to follow your finger through the six cardinal fields of gaze assesses extraocular muscle function and eye movement, not the "A" in PERRLA. This test evaluates cranial nerves III, IV, and VI, but it does not measure accommodation.
B. Moving your finger slowly toward the patient's nose and observing the pupils constrict and the eyes converge tests Accommodation, which is what the "A" in PERRLA represents. Accommodation involves the pupils adjusting for near vision (constricting) and convergence of the eyes, ensuring that the eyes can focus properly on close objects. This is the correct method for testing "A."
C. Shining a penlight into each eye and observing constriction of both pupils tests Pupillary Light Reflex, which corresponds to the "P" and "R" (Pupils Equal, Round, Reactive to Light) in PERRLA. This does not assess accommodation.
D. Asking the patient to focus on a distant object and then read a near vision card evaluates near and distance vision acuity, but it does not specifically test the pupillary constriction and convergence associated with accommodation.
Correct Answer is A
Explanation
Rationale:
A. Hyperthyroidism is characterized by an excess of thyroid hormones (T3 and T4), which increase the body’s basal metabolic rate. This accelerates metabolism, leading to weight loss despite normal or increased appetite. Unintentional weight loss is a hallmark clinical manifestation of hyperthyroidism and strongly suggests overactive thyroid function.
B. Cold intolerance is typically associated with hypothyroidism, where decreased thyroid hormone production slows metabolism and reduces heat generation. Clients with hyperthyroidism usually experience heat intolerance due to increased metabolic activity.
C. Fatigue and lethargy are more characteristic of hypothyroidism, resulting from slowed metabolism. In hyperthyroidism, clients often have increased energy, restlessness, and hyperactivity, although extreme hyperthyroidism can eventually lead to fatigue from prolonged hypermetabolic state.
D. Bradycardia (slow heart rate) is associated with hypothyroidism. In contrast, hyperthyroidism often causes tachycardia, palpitations, or increased heart rate, as thyroid hormones stimulate the cardiovascular system.
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