Which action would the nurse take if the patient brought to the emergency after hiking in the desert for 2 hours is confused, reports hallucinations, and has a temperature of 104.2°F (40.1°C), dark amber urine, and a serum sodium of 128 mEq/L? (Select all that apply.)
Remove tight clothing.
Administer acetaminophen.
Give salt tablets.
Place in cool water.
Initiate intravenous (IV) fluids.
Correct Answer : A,D,E
A. Removing tight clothing is correct because it allows for better heat dissipation and helps cool the patient.
B. Administering acetaminophen is incorrect as acetaminophen reduces fever from infection, not from heat stroke, which requires active cooling measures.
C. Giving salt tablets is incorrect as rapid sodium replacement can cause dangerous fluid shifts; IV fluids are preferred for controlled electrolyte correction.
D. Placing in cool water is correct because immersion cooling is one of the most effective methods to lower body temperature in heat stroke.
E. Initiating IV fluids is correct as the patient likely has dehydration and electrolyte imbalances, requiring fluid resuscitation with isotonic fluids.
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Related Questions
Correct Answer is D
Explanation
A. Administering an enema every third day may be too infrequent to effectively manage constipation. Enemas are generally not a first-line solution for constipation prevention in patients on long-term opioid therapy.
B. Constipation is nothing to worry about; take your medicine is incorrect because constipation is a common and preventable side effect of opioid use. It should be addressed proactively.
C. Only taking morphine when experiencing the most severe pain could lead to uncontrolled pain. It is important for cancer pain to be managed consistently, and adjusting the timing of medication is not recommended.
D. Increasing fluids and high-fiber foods, and using a mild laxative is the most appropriate recommendation. It helps prevent constipation, which is a common side effect of opioid use. Mild laxatives can also be helpful, but regular bowel care is essential.
Correct Answer is C
Explanation
A. Low levels of both HDL and LDL cholesterol is not desirable as low levels of HDL cholesterol are associated with a higher risk for heart disease.
B. Low levels of high-density lipoprotein (HDL cholesterol) are undesirable because HDL helps remove excess cholesterol from the bloodstream, and lower levels increase the risk of cardiovascular disease.
C. Low levels of low-density lipoprotein (LDL cholesterol) is the most desirable situation. Lower LDL levels reduce the risk of atherosclerosis and heart disease, making it important to lower these levels in patients with coronary artery disease.
D. Hypocholesterolemia (abnormally low cholesterol levels) is not typically targeted as a treatment goal and can be harmful in some situations, as cholesterol is essential for many bodily functions.
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