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NCLEX questions 20-2 Leave the first rating Students also studied Terms in this set (20) Vancouver Island UniversityNursing Save Thermoregulation NCLEX style Que...14 terms kjking2101Preview NCLEX Style Practice Questions Bur...100 terms akrrissman84Preview Drug Overdose and Poisoning testb...23 terms katirvin1Preview Snakeb 11 terms di-d The nurse caring for a client with hypothermia understands the compensatory mechanisms that are activated during this condition to decrease oxygen demands on the body. Which clinical manifestation should the nurse expect upon assessment for this client?(Select all that apply.) A.Increased heart rate B.Decreased heart rate C.Increased GI motility D.Increased respiratory rate E.Decreased respiratory rate BE The nurse is caring for a client diagnosed with frostbite.The nurse understands that which process occurs when tissue freezes? (Select all that apply.) A.Ice crystals form.B.Tissues and cells become edematous.C.Vascular permeability occurs.D.Thinning of the blood occurs.E.Intracellular potassium increases.
ABC
Which client is at the greatest risk for hypothermia?A.An 89-year-old client on a fixed income during cold winter months B.A 3-hour-old infant swaddled in a blanket, wearing a hat, and being held by the mother C.A worker who repairs industrial freezers D.A pregnant woman in her first trimester A The nurse is teaching a class about the clinical manifestations of hypothermia. Which information should the nurse include? (Select all that apply.) A.The clinical presentation of the client should determine the severity of hypothermia.B.Clients diagnosed with hypothermia should be encouraged to ambulate.C.A client diagnosed with hypothermia who is unresponsive and without a pulse should be declared dead.D.If frostbite is noted, the area should be rubbed vigorously.E.Clients diagnosed with hypothermia should undergo a complete body survey.
AE The nurse is assessing clients at a community health fair for risk of hypothermia. Which question by the nurse is appropriate? (Select all that apply.) A."How do you budget for increased heating bills in the winter?" B."Do your children have coats, hats, and gloves to wear at the bus stop?" C."Do you see your doctor at least twice a year for routine checkups?" D."How often do you drink alcohol?" E."Does your newborn regularly get exposure to natural sunlight?" ABD
A very-low-birth-weight (VLBW) newborn presents with hypothermia. Which nursing intervention should the nurse implement first?A.Place the undressed newborn in a radiant warmer.B.Monitor urine output.C.Monitor for dysrhythmia.D.Wrap the newborn in a blanket.D From an assessment of vital signs, the nurse learns that a client has a body temperature of 35.7°C (96.2°F). Which action should the nurse take? (Select all that apply.) A.Cover with a warmed blanket.B.Administer a tepid sponge bath.C.Provide oral hygiene.D.Cover the head with a cap.E.Provide warm oral fluids.
ADE The nurse provided teaching to a first-time new mother about preventing hypothermia in her baby. Which client statement indicates that the teaching is effective? (Select all that apply.) A."My baby is at risk for hypothermia because she has a thick layer of subcutaneous fat." B."My baby should wear a hat to avoid heat loss." C."Oral thermometers are an effective method to take my baby's temperature." D."I can use a pacifier thermometer to take my baby's temperature." E."My baby will shiver if she is cold." BD
The nurse is visiting an older adult client who lives at home alone. Which assessment should the nurse make to determine the risk of hypothermia? (Select all that apply.) A.Physical activity B.Diet C.Financial concerns D.Blood glucose E.Medications used ABCE Which client is most at risk to develop hypothermia?A.A 4-year-old diagnosed with croup B.A teenager who plays high school football C.An older adult on a fixed income who lives with his son D.A 3-year-old who lives near a pond D A client presents with hypothermia and frostbite of the toes with necrosis. Which clinical therapy should the nurse anticipate in response to the client's presentation?A.Rub areas of frostbite.B.Protect blisters from tearing.C.Place areas of frostbite in a basin of standing warm water.D.Prepare for amputation as necessary.D The nurse caring for a full-term newborn notes that the newborn's core body temperature is slightly subthermic.The nurse swaddles the newborn, places a cap on her head, and places her in a neutral thermic environment (NTE) in the nursery. Which additional intervention should the nurse implement to achieve normothermic body temperature?A.Obtain potassium level, as ordered.B.Observe muscular activity.C.Keep the newborn warm and dry.D.Monitor feeding activity.C
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