Thermal Injuries
The nurse is developing a plan of care for an older client that addresses interventions to prevent cold discomfort and the development of accidental hypothermia. The nurse should document which desired outcome in the plan of care? a. The client's fingers and toes are cool to touch b. The client's body temperature is 98 F c. The remains in a fetal position wjhn in bed d. The client complains of coolness in the hands and feet only
Correct answer: B Desired outcomes for nursing interventions to prevent cold discomfort and the development of accidental hypothermia include the following: hands and limbs are warm; body is relaxed and not curled; body temperature is greater than 97°F (36.1°C); the client is not shivering; and the client has no complaints of feeling cold
A client treated for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client states a need to perform which action? a. Increase fluid intake b. Resume full activity level c. Stay in a cool environment when possible d. Monitor voiding for adequacy of urine output
Correct answer: B Discharge instructions for the client hospitalized with hyperthermia include the prevention of heat-related disorders, increased fluid intake for 24 hours, self-monitoring of voiding, and the importance of staying in a cool environment and resting
A nurse working in an emergency room is caring for a client who has third degree frostbite to both lower extremities. The nurse should plan to take which of the following actions? a. Immerse the legs in cool water b. Elevate the legs c. Massage the legs d. Apply dry heat to the legs
Correct answer: B Frostbitten areas should be rewarmed in a circulating water bath for a time period of 30 to 40 min at a time. The temperature of the water should range from 40° to 42° C (104° to 108& F). When the extremities are rewarmed, it is necessary to handle the injured area carefully because the skin and tissues are fragile. Elevating the client's legs above the level of the heart is done to help prevent an increase in edema. Massaging the frostbitten areas increases the risk for further tissue damage and is contraindicated.The application of dry heat to frostbitten areas increases the risk for further tissue damage and is contraindicated
The nurse prepares to treat a client with frostbite of the toes. Which action should the nurse anticipate will be prescribed for this condition? a. Rapid and continuous rewarming of the toes after flushing returns b. Rapid and continuous rewarming of the toes in cold water for 45 minutes c. Rapid and continuous rewarming of the toes in hot water for 15 to 20 minutes d. Rapid and continuous rewarming of the toes in warm water bath until flushing of the skin occurs
Correct answer: D Acute frostbite is treated ideally with rapid and continuous rewarming of the tissue in a warm water bath for 15 to 20 minutes or until flushing of the skin occurs. Slow thawing or interrupted periods of warmth are avoided because they can contribute to increased cellular damage. Cold or hot water is not used. Thawing can cause considerable pain, and the nurse administers analgesics as prescribed
A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand? a. A pink, edematous hand b. Fiery red skin with edema in the nail beds c. Black fingertips surrounded by an erythematous rash d. A white color to the skin, which is insensitive to touch
Correct answer: D Assessment findings in frostbite include a white or blue color; the skin will be hard, cold, and insensitive to touch. As thawing occurs, flushing of the skin, the development of blisters or blebs, or tissue edema appears. Options 1, 2, and 3 are incorrect
A nurse is caring for a client who has meningitis, a temperature of 39.7° C (103.5° F), and is prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client must carefully be observed for which of the following complications? a. Dehydration b. Seizures c. Burns d. Shivering
Correct answer: D Dehydration is a complication that may occur as a result of a fever, however it is not considered a complication of the hypothermia blanket therapy. Seizures are a complication associated with meningitis and should be monitored in this client; however, it is not considered a complication of the hypothermia blanket therapy. Burns are associated with the improper use of heating pads, not a hypothermia blanket.The hypothermia blanket, if used improperly (at inappropriately low temperatures, or without skin protection), can cause the client to cool too fast, leading to shivering. To prevent heat loss from the skin, the body becomes peripherally vasoconstricted in an attempt to reduce heat loss. The body will also try to increase heat production by shivering, which can increase the metabolic rate by two to five times and in doing so greatly raise oxygen consumption
A new registered nurse (RN) is assigned to the care of a client hospitalized with a diagnosis of hypothermia. After consulting with an experienced RN, which statement by the new RN indicates understanding of likely assessment findings for this client? a. Increased heart rate and increased blood pressure b. Increased heart rate and decreased blood pressure c. Decreased heart rate and increased blood pressure d. Decreased heart rate and decreased blood pressure
Correct answer: D Hypothermia decreases the heart rate and the blood pressure because the metabolic needs of the body are reduced in this condition. With fewer metabolic needs, the workload of the heart decreases, resulting in decreased heart rate and blood pressure. Therefore, the remaining options are incorrect