NUR223 - Exam II

Treatment of heatstroke focuses on stabilizing the patient's _________ and rapidly reducing the _______ __________ through various cooling methods.

ABCs core temperature

_____________ frostbite involves muscle, bone, and tendon.

Deep

______________ are severe cramps in large muscle groups fatigued by heavy work

Heat cramps

______________ is a medical emergency resulting from failure of the hypothalamic thermoregulatory processes.

Heatstroke

Patients with ____________ hypothermia (93.2º F-96.8º F [34º C-36º C]) have shivering, lethargy, confusion, rational to irrational behavior, and minor heart rate changes.

mild

________________ is true tissue freezing, which results in the formation of ice crystals in the tissues and cells

Frostbite

Every effort is made to warm the hypothermia patient to at least ______º F (________º C) before the person is pronounced dead. The cause of death is usually _________________ _____________ _______________

86º F (30º C) refractory ventricular fibrillation.

______________ hypothermia (89.6° F-93.2°F [32° C-34° C]) causes rigidity, bradycardia, slowed respiratory rate, blood pressure only by Doppler, metabolic and respiratory acidosis, and hypovolemia. Shivering diminishes or disappears at temperatures ≤86º F (30º C).

Moderate

______________ hypothermia (below 89.6° F [32° C]) is a severe and potentially life-threatening situation that makes the person appear dead. Profound bradycardia, ventricular fibrillation, or asystole may be present.

Severe

The nurse is caring for a patient with severe hypothermia. What is the appropriate nursing intervention for this patient? a. Use radiant lights. b. Use air-filled warming blankets. c. Assist with warm water immersion. d. Provide heated, humidified oxygen.

d. Provide heated, humidified oxygen. Rationale The patient with severe hypothermia needs active internal or core rewarming with heated, humidified oxygen. The patient with mild hypothermia needs warmth from radiant lights. The patient with moderate hypothermia is provided air-filled warming blankets or is immersed in warm water. p. 1639

Prolonged exposure to heat over hours or days leads to _________ __________, a clinical syndrome characterized by fatigue, nausea, vomiting, extreme thirst, hypotension, elevated body temperature, and feelings of anxiety.

heat exhaustion

Brief exposure to intense heat or prolonged exposure to less intense heat leads to ________________.

heat stress

when taking temp of hyperthermic patient use temp from pulmonary artery catheter or bladder catheter if available because ____________________________.

these methods closely reflect core body temp

What describes heat exhaustion (select all that apply)? a. Volume and electrolyte depletion b. Treated with rapid cooling methods c. High risk of mortality and morbidity d. Rectal temperature of 99.6°F to 104°F (37.5°C to 40°C) e. Causes mild confusion, diaphoresis, and dilation of pupils

a. Volume and electrolyte depletion d. d. Rectal temperature of 99.6°F to 104°F (37.5°C to 40°C) e. Causes mild confusion, diaphoresis, and dilation of pupils In heat exhaustion, volume and electrolyte depletion, elevated rectal temperature, mild confusion, profuse diaphoresis, pupil dilation, and other symptoms occur. Heatstroke is characterized by an elevated core temperature (above 104° F [40° C] without sweating), the need for oxygen administration and treatment with cooling methods, and a high risk of mortality and morbidity.

Depending on the degree of hypothermia, rewarming can include __________, ____________, and _____________ _______ measures. Additional treatment strategies focus on managing and maintaining ABCs, correcting dehydration and acidosis, and treating cardiac dysrhythmias.

passive active external active internal

Defining characteristics of a hyperthermia patient related to increased metabolic rate

- ^ body temp above normal range - seizures - flushed skin (or ashen) - increased resp rate - tachycardia - skin warm to touch - diaphoresis

In the hyperthermic patient; monitor temp every ___________ to _________ until normal range and stable, then every ______ hours to maintain close surveillance for temp fluctuations & evaluate effectiveness of interventions

15 min 1 hour 4 hours

__________________ is defined as a core temperature less than 95º F (35º C).

Hypothermia

______________ frostbite involves skin and subcutaneous tissue, usually the ears, nose, fingers, and toes.

Superficial

A patient fell through the ice on a pond near his farm and is admitted to the emergency department with somnolence. Vital signs are blood pressure (BP) 82 mm Hg systolic with Doppler, respirations 9 breaths/minute, and core temperature of 90 o F (32.2 o C). The nurse should anticipate which intervention? a. Active core rewarming b. Immersion in a hot bath c. Rehydration and massage d. Passive external rewarming

a. Active core rewarming Rationale Active internal or core rewarming is used for moderate to severe hypothermia and involves the application of heat directly to the core. Immersion in a hot bath, rehydration, and massage are not appropriate interventions in the treatment of severe hypothermia. Passive rewarming is used in mild hypothermia. p. 1639

What is a factor that contributes to cold-related injuries? a. Age b. Obesity c. Dehydration d. Physical exertion

a. Age Rationale Age is a contributing factor to cold-related injuries. Older adults are more vulnerable to cold related injuries because of low body fat, low energy reserves, preexisting chronic illness, and use of medicines that can alter the response mechanism in an event of adverse environmental conditions. Obesity is associated with poor heat tolerance; hence obese people are at an increased risk of heat disorders in a hot and humid environment. Dehydration reduces the body's ability to sweat and maintain a normal temperature. Physical exertion generates heat; hence, any strenuous activity leads to heat stress. p. 1637

What are the clinical manifestations of superficial frostbite? a. Blisters b. Hot, dry skin c. Low muscle skill d. Profuse sweating

a. Blisters Rationale Patients with superficial frostbite injury experience blister formation within a few hours after the injury. The physiologic changes with heatstroke include hot, dry, and ashen-looking skin. With heatstroke, the nervous system is affected, lessening muscle skill and coordination. Neurologic symptoms are indicative of thermal injuries to the brain. Heat exhaustion leads to profuse sweating due to extended exposure to heat for long hours. p. 1637

Which part of the body is most vulnerable to frostbite in a superficial injury? a. Skin b. Bone c. Muscle d. Tendon

a. Skin In a superficial frostbite, the surface of the skin is affected. The appearance of the skin varies from waxy pale to blue to mottled in color. Dark-skinned persons run a higher risk, making them more prone to frostbite. In deep frostbite, the bones, muscles, and tendons are involved in the freezing process. The patient experiences loss of sensation on does not respond to touch.

Rewarming a frostbite patient is painful and requires ____________. The patient is monitored for __________________

analgesia complications.

A sportsman presents to the emergency department with suspected superficial frostbite on the feet. Which finding confirms this diagnosis? a. The skin is pale and cyanotic. b. The skin is hot, dry, and ashen. c. The skin appears waxy pale yellow to blue. d. The skin is white, hard, and insensitive to touch.

c. The skin appears waxy pale yellow to blue. Rationale In a localized cold injury like frostbite, the tissues freeze, resulting in the formation of ice crystals in the tissues and cells. If the frostbite is superficial in nature, then the skin is affected, making it appear waxy pale yellow to blue. The skin becomes discolored in irregular patches. The skin also feels crunchy and frozen to touch. The patient may complain of tingling, numbness, or a burning sensation. Heatstroke patients complain of hot, dry, and ashen skin. A patient with hypothermia shows pale and cyanotic skin. In a severe case of frostbite, the skin looks white, and is hard and insensitive to touch. The area has the appearance of deep thermal injury with mottling. p. 1637

The nurse is caring for an athlete with severe heat cramps in the leg. What intervention should the nurse perform? a. Place the patient in a cool area. b. Place a moist sheet over the leg. c. Place the leg in horizontal position. d. Provide parenteral replacement of sodium and water.

d. Provide parenteral replacement of sodium and water Rationale The nurse should provide oral or parenteral replacement of sodium and water. A patient experiencing heat exhaustion is placed in a cool area with a moist sheet over the body to decrease core body temperature through evaporative heat loss. The cramped leg should be elevated, not placed in a horizontal position, and should be gently massaged. p. 1637

The nurse is rewarming a patient being treated for frostbite. What indication should the nurse look for as a signal to discontinue the rewarming? a. The patient looks confused. b. The patient cannot bear the pain. c. The patient experienced hypotension. d. The core temperature reaches 89.6° to 93.2° F.

d. The core temperature reaches 89.6° to 93.2° F. Rationale The nurse should discontinue active rewarming only after the core body temperature reaches between 89.6° to 93.2° F. In a case of hypothermia the patient may experience metabolic disturbances causing confusion and withdrawal; however, the rewarming cannot be stopped midway. Rewarming does cause a substantial amount of pain. Analgesia is administered intravenously to treat the pain associated with rearming. It is normal for the patient to experience a very low blood pressure. p. 1638

With heatstroke, Increased _____________, _____________, and _________ _________ __________ deplete fluids and electrolytes, specifically sodium, and core temperature rises rapidly

sweating, vasodilation, and increased respiratory rate

with a hyperthermic patient use ________________ temp if core body temp devices are unavailable. Use ______ temp if above method or pulmonary artery catheter or bladder catheter is unavailable

tympanic membrane rectal temperature

Outcome Criteria of a hyperthermia patient

- temp is within normal range - resp rate and heart rate are within pts baseline range - skin is warm and dry

11. What heat-related emergency would the healthy athlete with inadequate fluid intake be most likely to experienceafter exercise? a. Heatstroke b. Heat attack c. Heat cramps d. Heat exhaustion

c. heat cramps Heat cramps are related to physical exertion during hot weather without adequate fluid replacement. Heatstroke is from failure of hypothalamic thermoregulatory processes. Heat exhaustion is from prolonged exposure to heat over hours or days.

The nurse creates a plan of care for a patient with frostbite of the hands. What is the most desirable outcome for the patient? a. Brisk capillary refill b. Adequate dietary intake c. Balanced fluid intake and output d. Blood pressure within normal limits

a. Brisk capillary refill Rationale The major dysfunction with frostbite is impaired circulation. Therefore measures to promote and maintain adequate circulation are the highest priority. This includes assessment of the nail beds for capillary refill. A good appetite, a balanced fluid intake and output, and normal blood pressure are not direct indicators in the treatment of frostbite. p. 1637

Which statement refers to frostbite? a. Condition of tissue damage due to freezing b. Condition of deficiency of oxygen in the tissues c. Condition of abnormally low core body temperature d. Condition caused by overexposure to high temperature

a. Condition of tissue damage due to freezing Rationale Frostbite is a cold-related injury caused by exposure to extreme weather. The body tissues freeze, which results in formation of ice crystals in the tissues and cells. Patients with hypoxia experience a fall in oxygen levels, which results in symptoms of inadequate oxygenation. Hypothermia occurs when the core body temperature falls abnormally low after the body is exposed to freezing temperatures. Heatstroke is caused by prolonged exposure to extremely high temperatures.

A nurse is administering cool fluids to a patient admitted to the hospital due to heatstroke. Which actions should the nurse take to avoid any complications? a. Control shivering. b. Administer antipyretics. c. Keep the patient clothed. d. Cover the patient with warm sheets.

a. Control shivering. Rationale The nurse should keep shivering under control. The heat produced by the muscles involved in the shivering activity leads to an increase in the core body temperature. Antipyretics can be administered to lower the body temperature but since the increase in temperature is not due to infection, these drugs are not effective in this case. In the event of a heatstroke, the nurse should remove any tight or layered clothing that covers most of the patient's skin. After removing the outer clothes, the patient should be wrapped in wet sheets to cool down the body. p. 1639 Test-Taking Tip: If the question asks for an immediate action or response, all of the answers may be correct, so base your selection on identified priorities for action.

A patient informs the nurse that he or she is planning on going camping and ice fishing next weekend. The patient is concerned about how cold it can get at night. What type of patient teaching should the nurse provide? Select all that apply. a. Keep head covered b. Dress in multiple layers c. Drink plenty of Gatorade d. Eat snacks such as dried fruits e. Dress in single layer of clothing

a. Keep head covered b. Dress in multiple layers d. Eat snacks such as dried fruits Rationale Dressing in multiple layers and keeping the head covered will help to keep the patient from losing body heat and help him or her to stay warm. Dried fruits have a high amount of carbohydrates that will help provide extra calories for increased heat. Drinking plenty of Gatorade and dressing in single layer would be something that would be needed to be done in a hot environment. p.1639

A patient reports tingling and burning sensations in the foot. The nurse records the patient's body temperature at 87° F (30.5° C) and notes that the patient has a waxy, pale yellow discoloration of the toes. Which nursing interventions will be beneficial for the patient? Select all that apply. a. Performing hemodialysis b. Performing peritoneal lavage c. Providing warmed intravenous fluids d. Cleaning the patient's toe with a scrub e. Covering the patient's head with cool, wet towels

a. Performing hemodialysis b. Performing peritoneal lavage c. Providing warmed intravenous fluids Rationale The presence of waxy, pale yellow, and mottled skin on the toes, along with a tingling and burning sensation, indicate that the patient has superficial frostbite. If the patient's body temperature is 87° F (30.5° C), this indicates moderate hypothermia. A patient with hypothermia has reduced peripheral blood flow. Therefore the nurse should perform extracorporeal circulation techniques, such as hemodialysis. The nurse should perform peritoneal lavage and administer warmed intravenous fluids in order to increase the patient's body temperature. The nurse should refrain from cleaning the patient's toe with a scrub, because it can cause further damage to the skin tissue. The nurse should cover the patient's head with a warm, dry towel to rewarm the patient. p. 1638

A snowstorm survivor is brought to the hospital in a comatose state. Initial assessment findings reflect a core body temperature of 85° F. Which nursing actions are necessary in the care of this patient? Select all that apply. a. Administer chlorpromazine. b. Administer warmed IV fluids. c. Immerse the patient in warm water. d. Place warm blankets on the patient. e. Administer heated and humidified oxygen.

b. Administer warmed IV fluids. e. Administer heated and humidified oxygen. Rationale A patient is diagnosed with severe hypothermia when the body temperature is below 86° F. Severe hypothermia is treated by using active internal or core rewarming method. Warm IV fluid heated at 98.6° F is administered by peritoneal lavage. Humidified oxygen heated to 111.2° F is administered to the patient. Chlorpromazine is used to control shivering in a patient. When the core body temperature is at 85° F, the body does not shiver, so chlorpromazine is not required. Warm water immersion is helpful in mild, not severe, hypothermia and is used when active external rewarming methods will bring relief to the patient. Placing warm blankets on a patient is a passive and spontaneous rewarming technique helpful in cases of mild, not severe, hypothermia. p. 1639

Which factors predispose an individual to heat stress? a. Opioid b. Alcohol c. Inability to swim d. Adequate clothing

b. Alcohol Rationale Alcohol affects the body's ability to regulate temperature, and hence, should be avoided, because it increases the sensation of warmth. Opioids suppress shivering and hence body temperature is regulated and so they do not lead to heat stress. The inability to swim can cause a submersion injury and is not a heat-related injury. Wearing adequate clothing suitable for the weather as well as wearing clothes that do not interfere with perspiration reduce heat stress. p. 1636 Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation.

While caring for a patient with heatstroke, the nurse suspects that the patient is at risk for skeletal muscle breakdown. Which symptom supports the nurse's suspicion? a. Weakness b. Color of urine c. Texture of skin d. Core body temperature

b. Color of urine Rationale The tea color or brown color of the urine is an indicator of kidney injury in a patient experiencing heatstroke. The breakdown of skeletal muscle leads to kidney injury. Weakness and fatigue in heatstroke is caused by extended exposure to heat. The texture of skin turns hot, dry, and ashen during heatstroke. Heat stress causes elevation in the core body temperature and is not an indicator of muscle breakdown. p. 1637

Which instruction should the nurse give to a patient to avoid cold-related injuries? a. Leave the head uncovered. b. Dress in layers for cold weather. c. Consume alcohol-based drinks. d. Reduce consumption of carbohydrates.

b. Dress in layers for cold weather. Rationale Cold-related injuries can be prevented by wearing adequate clothes suitable for the climate and environmental temperature. The head should be also covered to protect the extremities from being affected. Alcohol is extremely harmful in a cold climate because it causes peripheral vasodilation. Individuals should increase consumption of foods high in carbohydrates to gain extra calories useful in generating internal warmth during cold.

A homeless man is brought to the ED in severe hypothermia with a temperature of 85° F (29.4° C). What should the nurse expect to find on initial assessment? a. Shivering and lethargy b. Fixed and dilated pupils c. BP obtainable only by Doppler d. Respirations of 6 to 8 per minute

b. Fixed and dilated pupils Patients with profound hypothermia appear dead on presentation and exhibit fixed, dilated pupils; difficult-to- detect vital signs; unconsciousness; and apnea. Shivering is seen in mild hypothermia. Moderate hypothermia is characterized by slowed respirations, BP obtainable only by Doppler, and rigidity.

Which physiologic changes may be observed during heatstroke when, over a period of 10 to 15 minutes, a patient's sweat glands have stopped functioning and the core body temperature has increased? Select all that apply. a. Nausea b. Hot and dry skin c. Profuse sweating d. Loss of muscle coordination e. Temperature of 105° F (40.5ºC)

b. Hot and dry skin d. Loss of muscle coordination e. Temperature of 105° F (40.5ºC) Rationale Heatstroke occurs when the body's internal temperature control mechanism fails. Consequently, the physiologic changes cause the skin to turn dry and hot and the body temperature to rise to more than 104° F (40°C). The nervous system is affected leading to loss of muscle coordination. Nausea and weakness are present when a patient suffers from heat cramps. Heat exhaustion leads to profuse sweating due to extended exposure to heat for long hours. p. 1637

Which nursing intervention would be included in the exposure and environmental control assessment component of the primary survey in the emergency department? a. Securing the forehead to a backboard b. Keeping the patient warm with blankets c. Reassessing the level of consciousness d. Periodically performing a neurologic examination

b. Keeping the patient warm with blankets Rationale In the Exposure or Environmental Control step, the patient's clothes are removed for a thorough physical assessment. Once the patient is exposed, warming blankets, overhead warmers, and warmed IV fluids are used to limit heat loss, prevent hypothermia, and maintain privacy. A brief pain assessment is conducted under the disability step during primary survey to periodically reassess pain using standardized pain scale. The patient's forehead is secured to the backboard to achieve cervical spine stabilization and/or immobilization. A neurologic examination is a measure of the degree of disability, done to assess the patient's level of consciousness. p. 1632

During the wintertime, a patient comes into the emergency department acting very strange and confused. The nurse notes that the patient appears to be wet and is shivering. Vital signs read pulse 60 beats/minute, respirations 16 breaths/minute, temperature 93.9 o Fahrenheit, blood pressure 120/65. What would the nurse suspect? a. Deep frostbite b. Mild hypothermia c. Moderate hypothermia d. Moderate hyperthermia

b. Mild hypothermia Rationale Patients with mild hypothermia (93.2° to 96.8° F [34° to 36° C]) have shivering, lethargy, confusion, rational to irrational behavior, and minor heart rate changes. Patients with moderate hypothermia (86° to 93.2° F [30° to 34° C]) have rigidity, bradycardia, slowed respiratory rate, blood pressure obtainable only by Doppler, metabolic and respiratory acidosis, and hypovolemia. Patients with frostbite have skin that is white, hard, and insensitive to touch. The area has the appearance of deep thermal injury, with mottling gradually progressing to gangrene. The patients with hyperthermia have an increase in temperature. p. 1638

Which characteristics confirm deep frostbite? Select all that apply. a. The skin feels tingly. b. The skin appears white. c. The skin is insensitive to touch. d. The skin feels crunchy and frozen. e. The skin shows signs of gangrene.

b. The skin appears white. c. The skin is insensitive to touch. Rationale Deep frostbite affects the layers of the skin. The skin texture is white, hard, and does not respond to touch. The signs and symptoms of superficial frostbite include tingling, numbness, and burning sensation on the skin. With deep frostbite, the affected area will gradually become gangrenous, but does not appear so right away. The surface of the skin feels crunchy and frozen to the touch with superficial frostbite. p. 1637

The nurse is caring for a patient with superficial frostbite on the nose, fingers, and toes. What interventions should the nurse perform? Select all that apply. a. Massage the injured area. b. Use warm soaks for the face. c. Use a heavy blanket to keep the patient warm. d. Apply a sterile dressing following debridement. e. Immerse toes and fingers in a water bath at 98.6° to 104° F.

b. Use warm soaks for the face d. Apply a sterile dressing following debridement. e. Immerse toes and fingers in a water bath at 98.6° to 104° F. Rationale The nurse should use warm soaks for the face. Blisters that form within a few hours should be debrided and covered with a sterile dressing. The affected toes and fingers should be immersed in a water bath at 98.6° to 104° F. The frostbitten area should be handled carefully; massaging causes damage to the tissues. The nurse should avoid using heavy blankets for the patient because they could cause friction and sloughing of damaged tissue. p. 1638

The nurse reviews a patient's medical record. After informing the primary health care provider, what important actions should the nurse take? Select all that apply. ** Body Temp: 106 F with shivering ** Resp. Rate: 25 breaths/min ** BP: 80/50 mmHg ** UA: presence of myoglobin ** Mental Status: halluconations, combativeness, confused a. Administer salt tablets. b. Administer antipyretics. c. Administer chlorpromazine. d. Assess for tea-colored urine. e. Obtain blood-clotting studies. f. Administer fluids and electrolytes

c. Administer chlorpromazine. d. Assess for tea-colored urine. e. Obtain blood-clotting studies. f. Administer fluids and electrolytes Rationale A body temperature greater than 104° F with shivering, an increased respiratory rate, hypotension, myoglobinuria, hallucinations, combativeness, and loss of coordination are clinical presentations of heatstroke. Chlorpromazine can effectively reduce shivering in the patient. Therefore the nurse will administer this medication to the patient. The patient with myoglobinuria is characterized by tea-colored urine. Therefore the nurse will check whether the patient's urine is tea colored. The nurse obtains blood-clotting studies in the patient to monitor for signs of disseminated intravascular coagulation (DIC). Heatstroke is also characterized by decreased electrolytes, particularly sodium levels. Therefore the nurse administers fluids and electrolytes to the patient. Antipyretics reduce the body temperature that is elevated due to infection, but not temperature due to heatstroke. Therefore antipyretics do not help to reduce this patient's body temperature. Salt tablets can cause gastric irritations and hypernatremia in the patient. Therefore they should not be administered to the patient. p. 1637

What finding indicates mild hypothermia? a. Body temperature of 84° F (28.8ºC) b. Body temperature of 86° to 93.2ºF, (32º to 34ºC) c. Body temperature of 93.2º to 98.6º F, (34º to 35ºC) d. Body temperature of 99.6º to 105.8ºF (37.5º to 41ºC)

c. Body temperature of 93.2º to 98.6º F, (34º to 35ºC) Rationale Assessment findings in hypothermia are variable and depend on the core body temperature of the patient. In mild hypothermia, the patient experiences shivers and reports a body temperature between 93.2 and 96.8 oF. In moderate hypothermia, the shivering diminishes or disappears and the body temperature is maintained between 86 and 93.2 oF. Severe hypothermia is a life-threatening situation when the body temperature is at or below 86 o. At 86 o F, the patient appears dead. p. 1638

Priority Decision: A patient is brought to the ED following a skiing accident after which he was not found for several hours. He is rigid and has slowed respiratory and heart rates. What should the nurse do first during the primary assessment of the patient? a. Initiate active core rewarming interventions. b. Monitor the core temperature via the axillary route. c. Manage and maintain ABCs (airway, breathing, circulation). d. Expose the patient to check for areas of frostbite and other injuries.

c. Manage and maintain ABCs (airway, breathing, circulation). Rigidness, bradycardia, and slowed respiratory rate are signs of moderate hypothermia. The ABCs are the initial priority. Active core rewarming is indicated for moderate to severe hypothermia. Axillary temperatures are inadequate to monitor core temperature, so esophageal, rectal, or indwelling urinary catheter thermometers are used. The patient should be assessed for other injuries but should not be exposed to prevent further loss of heat.

The patient is brought to the emergency department feeling weak, and presenting with dehydration, a body temperature of 102° F (38.8ºC), and pale skin. What are the appropriate nursing interventions in this situation? Select all that apply. a. Using a warm sheet b. Ingesting salt tablets c. Placing patient in a cool environment d. Providing high-flow oxygen in a nonrebreather mask e. Managing and maintaining airway, breathing, and circulation

c. Placing patient in a cool environment d. Providing high-flow oxygen in a nonrebreather mask e. Managing and maintaining airway, breathing, and circulation Rationale Heat exhaustion usually occurs in individuals engaged in strenuous activity in hot, humid weather. It is characterized by fatigue, dehydration, and a mild to severe temperature elevation between 99.6° to 104° F. Initial intervention starts with the assessment of the airway, breathing, and circulation. The patient is placed in a cool area where rapid cooling measures are initiated. The nurse removes the patient's clothes, places a wet sheet over the patient, and places the patient in front of a fan. The patient is provided with high-flow oxygen in a nonrebreather mask. Salt tablets should not be used because of potential gastric irritation and hypernatremia. Moist sheets, rather than warm sheets, should be placed over the patient to decrease core temperature through evaporative heat loss. p. 1637

Which core body temperature readings confirm hyperthermia? a. 86° to 93.2° F (32ºC to 34ºC) b. 93.2° to 96.8° F (34ºC to 36ºC) c. Less than or equal to 86° F (32ºC) d. 99.6° to 105.8° F (37.5 ºC to 41ºC)

d. 99.6° to 105.8° F (37.5 ºC to 41ºC) Rationale Hyperthermia indicates an elevated core body temperature. Heat exhaustion causes hyperthermia and is indicated when the core body temperature is at 99.6° F to 105.8° F. Hypothermia in a patient indicates low core body temperature. Mild hypothermia is reported at 93.2° F to 96.8° F, moderate hypothermia at 86° F to 93.2°F, and severe hypothermia is less than or equal to 86° F. p. 1637

An elderly patient is being discharged from the hospital after treatment for heat cramps sustained during a strenuous workout. What should the nurse emphasize during discharge teaching? a. Stay outdoors b. Do not use salt tablets c. Drink caffeinated drinks d. Avoid intense activity for at least 12 hours

d. Avoid intense activity for at least 12 hours Rationale The nurse should instruct the patient not to exercise or do any strenuous or intense activity for at least 12 hours after discharge. The patient should stay indoors in a cool, low-humidity environment. Salt intake should be encouraged to increase the low sodium level. Caffeinated drinks should be avoided, because they cause dehydration. p. 1637 Test-Taking Tip: Sometimes the reading of a question in the middle or toward the end of an exam may trigger your mind with the answer or provide an important clue to an earlier question.

Which drug controls shivering in a patient being treated for hyperthermia? a. Mannitol b. Analgesia c. Antihistamine d. Chlorpromazine

d. Chlorpromazine Rationale Treatment of a patient with hyperthermia focuses on lowering the core body temperature. Chlorpromazine intravenously (IV) administered is the preferred drug used to control shivering in instances when aggressive temperature reduction measures are required. Mannitol is widely used in treatment of cerebral edema in patients with submersion injuries. IV analgesia is used in the treatment of cold injuries. Antihistamines are administered IV to relieve different types of allergies and reactions. p. 1637 Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

What differentiates heatstroke from heat exhaustion? a. Fatigue b. Perspiration c. Mental status d. Core body temperature

d. Core body temperature Rationale In heat exhaustion, the core temperature of a patient is 99.6° to 104° F, and that of a patient with heat stroke is greater than 104° F. Extended exposure to heat leads to heat stress characterized by fatigue and weakness, which occurs during heatstroke and heat exhaustion. Heatstroke patients sweat profusely; however, increased sweating in heat exhaustion eventually causes the sweat glands to stop working, leading to absence of perspiration. The mental status of the patient is affected in heatstroke as well as in heat exhaustion as a result of thermal injury to the brain. p. 1637 Test-Taking Tip: Be aware that information from previously asked questions may help you respond to other examination questions.

The nurse identifies that a patient is at an increased risk for frostbite if the patient has what condition? Select all that apply. a. Abdominal pain b. Hyperthyroidism c. Urinary retention d. Diabetes mellitus e. Peripheral vascular disease

d. Diabetes mellitus e. Peripheral vascular disease Rationale Increased blood glucose levels and decreased blood supply to the peripheral tissue impair tissue integrity and increase the risk of frostbite. Therefore a person with diabetes mellitus and peripheral vascular disease has a higher risk of frostbite. Abdominal pain, an increase in thyroid hormone levels, or decreased urine outflow do not impair tissue integrity, so these conditions do not increase the risk of frostbite. p. 1637

What should the nurse do during rewarming of a patient's toes that have suffered deep frostbite? a. Apply sterile dressings to blisters b. Place the feet in a cool water bath. c. Massage the digits to increase circulation. d. Ensure that IV analgesics are administered.

d. Ensure that IV analgesics are administered. Rewarming of frostbitten tissue is extremely painful, and IV analgesia should be administered during the process. Blisters form in hours to days following the injury and are not an immediate concern. The affected part is submerged in a 98.6° F to 104° F (37°C to 40° C) circulating water bath. Massage or scrubbing of the tissue should be avoided because of the potential for tissue damage.

A patient comes into the emergency department complaining of extreme thirst and vomiting on a very hot day. The nurse assesses that the patient has profuse diaphoresis and is ashen in color. Vital signs are blood pressure 90/50, pulse 98, and temperature is 101 o Fahrenheit. Which of the following is the immediate priority for the nurse? a. Administer salt tablets b. Initiate oral fluid and electrolyte replacement c. Start intravenous fluid bolus of lactated Ringer's d. Place the patient in a cool area and remove any restrictive clothing

d. Place the patient in a cool area and remove any restrictive clothing Rationale The patient is experiencing heat exhaustion, and the initial treatment step is to place the patient in a cool area and remove any restrictive clothing. The nurse would not administer salt tablets, because this could lead to complications such as gastric irritation or hypernatremia. The nurse would not administer oral fluid and electrolyte replacement for a patient experiencing nausea or vomiting. An intravenous bolus may be started, but it would consist of 0.9% normal saline, not lactated Ringers. p. 1637

When treating a severely hypothermic patient, what is the clinical reason behind warming the patient's core first before the extremities? a. To prevent pain and discomfort b. To stimulate muscle coordination c. To stop the patient from shivering d. To prevent a further drop in temperature

d. To prevent a further drop in temperature Rationale The patient is at risk of a further drop in temperature during the warming procedure when the cold blood flows back into the central circulation. Severely hypothermic patients should have the core rewarmed before the extremities. Analgesia is administered intravenously to tackle the pain associated with rewarming. Muscle coordination is stimulated by the nervous system. Neurologic symptoms are indicative of thermal injuries to the brain and, hence rewarming the core does not impact the nervous system. Severe hypothermic patients stop shivering when the core body temperature is below 86° F. p. 1639 Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options .