Nokea
Which factors increase the risk for hypothermia in an older client? Select all that apply.
- A. Burns
- B. Anemia
- C. Alcohol abuse
- D. Hypoglycemia
- E. Hyperthyroidism
- F. Poor thermoregulation
Correct Answer: A,B,C,D,F
Rationale: The median oral temperature of an older client is 96.8^{\circF}\left(36^{\circC}\right) . Environmental temperatures below 65^{\circF}\left(18^{\circC}\right) may cause a serious drop in core body temperature to 95^{\circF}\left(35^{\circC}\right) or less in the older client. Numerous factors increase the risk of hypothermia in the older client, including conditions that increase heat loss (e.g., burns); conditions that decrease heat production such as hypothyroidism, hypoglycemia, or anemia; medications or substances that interfere with thermoregulation, such as alcohol; or thermoregulatory impairment (failure to sense cold).
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The nurse is preparing to care for the mother of a preterm infant. When should the nurse plan to begin discharge planning?
- A. When the mother is in labor
- B. When the discharge date is set
- C. After stabilization of the infant during the early stages of hospitalization
- D. When the parents feel comfortable with and can demonstrate adequate care of the infant
Correct Answer: C
Rationale: Discharge planning begins at admission of the preterm infant. The determination of the services, needs, supplies, and equipment requirements should not be made on the day of discharge. Beginning planning during labor is incorrect because the outcome of the delivery is not known. At discharge or when the parents feel comfortable caring for their infant are incorrect because these times are much too late to make the plans that need to be made.
Cyclophosphamide is prescribed for the client diagnosed with breast cancer, and the nurse provides instructions to the client regarding the medication. Which statement by the client indicates the need for further teaching?
- A. If I lose my hair, it will grow back.
- B. If I develop a sore throat, I should notify the doctor.
- C. I need to limit my fluid intake while taking this medication.
- D. I need to avoid contact with anyone who recently received a live virus vaccine.
Correct Answer: C
Rationale: Cyclophosphamide can cause hemorrhagic cystitis, requiring copious fluid intake (2–3 liters/day) to prevent it, not fluid restriction. Hair regrowth, reporting sore throat (indicating infection), and avoiding live virus vaccine contacts are correct due to immunosuppression.
The nurse provides home care instructions to a client diagnosed with Cushing's syndrome. The nurse determines that the client understands the hospital discharge instructions if the client makes which statement?
- A. I need to eat foods low in potassium.
- B. I need to check the color of my stools.
- C. I need to check the temperature of my legs twice a day.
- D. I need to take aspirin rather than acetaminophen for a headache.
Correct Answer: B
Rationale: Cushing's syndrome results in an increased secretion of cortisol. Cortisol stimulates the secretion of gastric acid, and this can result in the development of peptic ulcers and gastrointestinal bleeding. The client should be encouraged to eat potassium-rich foods to correct the hypokalemia that occurs with this disorder. Cushing's syndrome does not affect temperature changes in the lower extremities. Aspirin can increase the risk for gastric bleeding and skin bruising.
A 9-month-old child is registered to attend a local childcare clinic. Upon initial intake, the nurse discovers the child has received the first and second dose of the hepatitis B vaccine. What is the best course of action for the nurse to recommend to the parents?
- A. no action; a third dose of the vaccine is not recommended
- B. immediately inoculate the child given the high risk of not having a third vaccine
- C. wait until the child is 12 months to give the vaccine
- D. schedule the child for the third vaccine at the earliest convenience
Correct Answer: D
Rationale: The hepatitis B vaccine requires three doses, with the third typically given between 6-18 months. Scheduling the third dose at the earliest convenience ensures timely protection. Option A is incorrect, B is unnecessarily urgent, and C delays protection.
The nurse has taught the client with pleurisy about measures to promote comfort during recuperation. The nurse determines that the client has understood the information if the client states the need to follow which instruction?
- A. Try to take only small, shallow breaths.
- B. Take as much pain medication as possible.
- C. Lie on the affected side as much as possible.
- D. Splint the chest wall during coughing and deep breathing.
Correct Answer: D
Rationale: The client with pleurisy should splint the chest wall during coughing and deep breathing. Taking small, shallow breaths promotes atelectasis. The client should take medication cautiously so that adequate coughing and deep breathing are performed and an adequate level of comfort is maintained. The client may also lie on the affected side to minimize the movement of the affected chest wall.