The home health nurse in Wyoming gives instruction to an 80-year-old patient in the prevention of hypothermia.
Which information should the nurse include? (Select all that apply.)
Wear multiple layers of clothing.
Drink warm fluids from a thermos.
Wear gloves and earmuffs.
Wear a loose-fitting hat.
Correct Answer : A,B,C,D
Choice A rationale
Wearing multiple layers of clothing helps to trap body heat, preventing hypothermia.
Choice B rationale
Drinking warm fluids from a thermos helps maintain body temperature by providing warmth.
Choice C rationale
Wearing gloves and earmuffs prevents heat loss from extremities, which is essential in preventing hypothermia.
Choice D rationale
Wearing a loose-fitting hat prevents heat loss from the head, which is a significant source of body heat loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Applying powder to sensitive skin areas can cause dryness and irritation, exacerbating SLE symptoms. Powders can also block pores, increasing the risk of skin infections.
Choice B rationale
Using a strong protein shampoo is not relevant to managing SLE. It won't address the photosensitivity or skin issues commonly associated with SLE.
Choice C rationale
Sun protection is crucial for SLE patients due to photosensitivity. UV exposure can trigger flare-ups, making a sun-blocking agent with SPF 30 or higher essential for skin protection.
Choice D rationale
Moisturizing lotions help prevent dryness and protect the skin barrier, which is important in SLE management. Avoiding them can lead to skin complications.
Correct Answer is ["A","C"]
Explanation
Choice A rationale:
Tachycardia: Heatstroke often leads to an elevated heart rate due to the body's attempt to cool down and compensate for increased body temperature. The heart rate of 120 beats per minute noted in the client is consistent with tachycardia.
Choice B rationale:
Hallucinations: While confusion and disorientation are common symptoms of heatstroke, hallucinations are not typical findings associated with heatstroke. Therefore, this is not a consistent finding for this diagnosis.
Choice C rationale:
Skin is hot, dry: One of the hallmark signs of heatstroke is hot, dry skin, which results from the body's inability to regulate its temperature effectively. The client's skin being hot to the touch and dry aligns with this characteristic.
Choice D rationale:
Bradycardia: This is characterized by a slower than normal heart rate. Since the client presents with a heart rate of 120 beats per minute, which indicates tachycardia, bradycardia is not a finding consistent with heatstroke.
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