Which patient assessment data does the nurse recognize could contribute to an older adult's risk of hyperthermia?
Keeps room temperature at 72°F
Has a history of osteoarthritis
Takes furosemide 40 mg daily
Bathes daily with a hot shower
The Correct Answer is C
A. Keeps room temperature at 72°F.
Explanation: Maintaining a room temperature of 72°F is generally considered comfortable and is not likely to contribute to hyperthermia, especially when compared to higher temperatures. However, it's essential to consider individual preferences and comfort levels.
B. Has a history of osteoarthritis.
Explanation: Osteoarthritis itself is not directly associated with an increased risk of hyperthermia. However, limitations in mobility or difficulties with self-care due to osteoarthritis might indirectly impact the ability to stay cool and hydrated, so comprehensive care should consider the overall health status of the individual.
C. Takes furosemide 40 mg daily.
Explanation: Furosemide is a diuretic that increases urine production, leading to fluid loss. Dehydration or electrolyte imbalances resulting from diuretic use can contribute to an increased risk of hyperthermia, especially in hot weather. It's important for healthcare providers to monitor and manage medications, considering their potential effects on fluid balance and thermoregulation.
D. Bathes daily with a hot shower.
Explanation: While taking hot showers may contribute to temporary elevation of body temperature, bathing alone may not be a significant contributor to hyperthermia. However, if an older adult has difficulty tolerating heat or maintaining hydration, it's essential to consider the cumulative impact of various factors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A. The Global Deterioration Scale
Explanation: The Global Deterioration Scale (GDS) is a tool used to assess the cognitive function and stage of cognitive decline in individuals, especially those with dementia.
B. Mini Mental State Exam (MMSE)
Explanation: The Mini Mental State Exam (MMSE) is a widely used tool to assess cognitive function and screen for cognitive impairment. It evaluates various cognitive domains, including orientation, memory, attention, and language.
C. Older American's Resources and Services (OARS)
Explanation: The Older American's Resources and Services (OARS) is not a cognitive assessment tool. It is a comprehensive assessment tool that covers various domains, including physical health, mental health, and social resources.
D. Mini-Cog
Explanation: The Mini-Cog is a brief cognitive screening tool that includes a three-item recall test for memory and a clock-drawing task. It is used to quickly assess cognitive function and detect potential cognitive impairment.
E. The Barthel Index
Explanation: The Barthel Index is not a cognitive assessment tool. It is a tool used to assess an individual's ability to perform activities of daily living (ADLs), providing information about their functional independence rather than cognitive status.
Correct Answer is A
Explanation
A. Constipation.
Explanation: Constipation is a common side effect of opioid medications like morphine. Older adults, particularly those on bed rest or with reduced mobility, are already at an increased risk of constipation. Morphine further contributes to this risk by slowing down bowel motility. Preventive measures such as promoting adequate hydration, encouraging fiber intake, and considering stool softeners can help prevent constipation in this scenario.
B. Poor solid food intake.
Explanation: While monitoring and addressing poor solid food intake are important for overall nutritional status, it may not be the immediate priority related to morphine use and postoperative care.
C. Poor liquid intake.
Explanation: Ensuring adequate fluid intake is important for overall hydration, but constipation is a more specific and immediate concern associated with opioid use.
D. Diarrhea.
Explanation: Diarrhea is not a common side effect of morphine and is less likely to be the priority for preventive care in this situation. Constipation is a more anticipated concern when opioids are prescribed.
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