The nurse is caring for a patient who collapsed after working outside on a hot day. The patient is disoriented with hot, dry skin and a heart rate of 140 beats/minute. Which temperature will the nurse expect the patient to have?
104.4°F
99.2 F
100.8°F
102.2 F
The Correct Answer is A
A. 104.4°F. This temperature is consistent with heatstroke, a life-threatening condition characterized by hot, dry skin, confusion, and tachycardia. Heatstroke occurs when the body fails to regulate temperature, often exceeding 104°F (40°C).
B. 99.2°F. A temperature of 99.2°F is only slightly elevated and does not match the severe hyperthermia expected in heatstroke.
C. 100.8°F. While this temperature is above normal, it is not high enough to indicate heatstroke, which typically involves temperatures above 104°F.
D. 102.2°F. This temperature suggests heat exhaustion, a milder form of heat-related illness, but heatstroke involves higher temperatures exceeding 104°F.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Have the patient drink hot liquids. An unconscious patient cannot safely swallow, and forcing fluids could lead to aspiration. Additionally, internal warming should be done cautiously to avoid complications like shock.
B. Bathe the patient to promote shivering. Shivering is the body’s natural response to generate heat, but bathing a hypothermic patient would further lower body temperature and worsen the condition.
C. Remove restrictive items of clothing. While removing wet or restrictive clothing is important, it is not the priority over actively warming the patient. Hypothermia management focuses on gradual rewarming.
D. Wrap the patient in warmed blankets. The priority in hypothermia is gradual external rewarming using warmed blankets to prevent further heat loss and safely increase body temperature.
Correct Answer is C
Explanation
A. Auscultation. Auscultation involves listening to internal body sounds, usually with a stethoscope, such as heart, lung, or bowel sounds. It is not used for assessing the radial pulse.
B. Percussion. Percussion is the technique of tapping on body surfaces to assess underlying structures, such as detecting fluid in the lungs or assessing organ size. It is not used to assess pulses.
C. Palpation. Palpation involves using the fingers to feel for the radial pulse by applying gentle pressure over the radial artery at the wrist. This is the correct method for assessing a patient's radial pulse.
D. Inspection. Inspection involves visually examining the patient for abnormalities such as skin color, swelling, or deformities. It does not provide information about pulse rate or rhythm.
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