The home health nurse is instructing a caregiver about caring for a patient with hypothermia. The nurse recognizes that further instruction when the caregiver states, "I will
instruct the patient to remain on strict bed rest
provide the patient with additional blankets"
encourage the patent to increase his muscle activity”
offer fluids to the patient if permitted
The Correct Answer is C
A. Keeping the patient on bed rest is appropriate as it conserves energy and helps prevent further heat loss.
B. Providing additional blankets is a correct intervention to warm the patient gradually.
C. Increasing muscle activity is contraindicated because it could cause vasoconstriction and worsen hypothermia, as the body focuses on preserving core temperature.
D. Offering fluids (if permitted) is correct as hydration can help restore normal body temperature regulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Pulse deficit refers to the difference between the apical and radial pulse, not a silence between sounds during blood pressure measurement.
B. Diastolic refers to the phase of the blood pressure cycle when the heart is at rest, not to a silent period.
C. An auscultatory gap is a period of silence between the systolic and diastolic sounds heard when taking blood pressure. It can be indicative of arterial stiffness or other vascular issues.
D. Widened pulse pressure refers to the difference between systolic and diastolic pressures, not a silence during auscultation.
Correct Answer is A
Explanation
A. Performing a quick focused assessment at the beginning of each shift allows the nurse to identify any immediate needs or changes in the patient's condition, ensuring timely and appropriate care. This practice helps in maintaining continuity of care and promptly addressing any issues that may arise during the shift.
B. While a comprehensive assessment is typically performed upon admission to the unit, a quick focused assessment is not specifically required at this time. The initial comprehensive assessment will cover all necessary information.
C. At discharge, the focus is on providing discharge instructions and ensuring the patient understands their care plan after leaving the facility. A quick focused assessment is not typically performed at this time.
D. While it is important to check on the patient in the morning, a quick focused assessment is not specifically required at this time. The beginning of each shift is a more critical time to perform this assessment to ensure continuity of care.
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