1. A client is demonstrating heat stroke manifestations. Identify three (3)
manifestations of this condition and three (3) interventions that need to
be implemented <Ans> Manifestations of a heat stroke include hot, dry skin,
hypoten- sion, tachypnea, tachycardia, anxiety, confusion, unusual behavior, seizures,
and coma.Rapid cooling must be achieved.Remove the client's clothing. Place ice packs
over the major arteries (axillae, chest, groin, neck).Immerse the client in a cold-water
bath.Wet the client's body, then fan with rapid movement of air.(Fundamentals RM
Chapter 13)
2. A nurse is caring for a client with hyponatremia.What manifestations should
the nurse anticipate <Ans> Vital signs - hypothermia, tachycardia, rapid thready
pulse, hypotension, orthostatic hypotension (vital signs can vary based on state of
ECF volume)Neuromusculoskeletal - headache, confusion, lethargy, muscle weakness
to the point of possible respiratory compromise, fatigue, decreased deep-tendon
reflexes, seizuresGastrointestinal - increased motility, hyperactive bowel sounds,
abdominal cramping, nauseaLaboratory TestsSerum sodium - Decreased: less than 136
mEq/LSerum osmolarity - Decreased: less than 270 mOsm/L(Fundamentals RM
Chapter 58)
3. A nurse is assisting with the preparation a community health education class
for young adults. What are three (3) health risks for this population that could
be presented during the health class <Ans> Young adults should be educated on
the following health risks: • Substance use disorders • Periodontal disease due to
poor oral hygiene • Unplanned pregnancies - a source of high stress • Sexually
transmitted infections (STIs) • Infertility • Work-related injuries or exposures • Violent
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