The nurse is triaging an older client in the emergency department. The nurse notes the client has a heart rate 145 beats/minute, respiratory rate 28 breaths/min, temperature 106° F (41.1°C), and the client appears agitated and will not hold still long enough to get an accurate blood pressure reading. The client's family reports they have been outdoors in the hot sun all morning and approximately 60 minutes ago the client began acting very confused. What is the priority nursing intervention?

Give acetaminophen 1000 mg PO for fever

Offer the client warm blankets for shivering

Start IV fluids using a warmed solution

Start IV fluids using a cooled solution

Answer and Explanation

The Correct Answer is D

A. Acetaminophen is not effective in treating heat stroke, as this condition is not caused by an infection or hypothalamic reset but by failure of thermoregulation.
B. Warm blankets would worsen hyperthermia and are contraindicated in heat stroke.
C. Warm IV fluids would further increase body temperature, worsening the client’s condition.
D. The client is showing signs of heat stroke (very high temperature, confusion, tachycardia, tachypnea, and environmental exposure). The priority intervention is rapid cooling, which includes using cooled IV fluids, cooling blankets, ice packs to the groin/axillae, and removing excess clothing. This helps to lower the dangerously high core temperature and prevent organ failure.

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Correct Answer is D

Explanation

A. Providing brochures is informative but may not adequately support the client’s emotional adjustment to a new chronic illness.
B. Suggesting the client get affairs in order is premature and could increase anxiety rather than promote healthy coping.
C. Telling the client their family will be trained may be reassuring but does not directly address the client’s need to process feelings and cope with the diagnosis.
D. Encouraging the client to join a support group offers an opportunity to share experiences, gain emotional support, and learn coping strategies from others with similar conditions, which is the most therapeutic intervention to promote adaptation.

A. Increasing the dose of muscle relaxants B. Taking a hot bath at least three times a week. C. Avoiding naps during the day D. Working with Occupational and Physical Therapy

Correct Answer is D

Explanation

A. Muscle relaxants (e.g., baclofen) are used to control spasticity in MS, but increasing the dose does not target fatigue. In fact, higher doses can increase drowsiness and worsen fatigue.

B. Heat can exacerbate symptoms in MS (Uhthoff’s phenomenon), including fatigue, muscle weakness, and visual disturbances. Hot baths should be avoided.

C. Clients with MS often benefit from energy conservation techniques, which may include short, planned rest periods or naps. Avoiding all naps can worsen exhaustion.

D. Occupational and physical therapy teach clients energy conservation, pacing activities, and safe exercise routines, which are highly effective strategies for reducing fatigue in MS.

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Blood Pressure	118/78 mmHg
Heart Rate	112 beats/minute
Respiratory Rate	22 breaths/minute
Temperature	102.8 F (39.3 C)
WBC	16000 (Ret: 4000-11000)
BUN	24 mg/dL (Ref: 8-20 mg/dL)
Creatinine	1.1 mg/dL (Ref: 0.6-1.2 mg/dL)

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who was recently diagnosed with chronic renal failure. Which is the most appropriate nursing intervention to assist the client in coping with the diagnosis?

Correct Answer is D

Explanation

The nurse is caring for a client with multiple sclerosis (MS). The client tells the nurse the hardest thing to deal with is the fatigue. When teaching the client how to reduce fatigue, what action should the nurse suggest?

Correct Answer is D

Explanation

The nurse is performing an assessment on a child with varicella and notices the child scratching the lesions. Which nursing intervention will the nurse perform to provide comfort at this time?

The nurse is caring for a client who states they have swelling in their knee, pain, and crepitus after running. What part of the client's health history will the nurse note as a possible cause of their symptoms?

The nurse is caring for a client who has peripheral neuropathy who has developed a foot ulcer. The client's caregiver asks, "How could this have happened?" What is the nurse's best response(s)? (Select all that apply)

The nurse is providing teaching to a young adult who is at risk for early-onset osteoporosis. Which intervention should the nurse suggest?

The nurse is assessing a client in the clinic. Which assessment findings indicate that the client may have benign prostatic hyperplasia (BPH)? (Select all that apply)

The nurse in the emergency department (ED) has just received a client with bright red emesis and a suspected stomach perforation related to peptic ulcer disease (PUD). What is the priority nursing action?

The nurse is caring for a client with cellulitis on the leg. Which statement by the client indicates a need for additional education regarding cellulitis?