The nurse should expect to assess which manifestations in a patient with profound hypothermia?
A) Absent neurological reflexes, asystole
B) Absent muscle reflexes, undetectable pulse
C) J-waves on ECG, exaggerated tendon reflexes
D) Agitation, vigorous shivering
A) Absent neurological reflexes, asystole
Explanation: A) In profound hypothermia, with a core temperature less than 17°C, the patient has absent neurological reflexes, absent muscular activity, and asystole.
B) In deep hypothermia, with a core temperature less than 17-29°C, the patient has absent muscle reflexes, an undetectable pulse, and fixed and dilated pupils.
C) In moderate hypothermia, with a core temperature less than 29-34°C, the patient has J waves on ECG, premature ventricular beats, stupor, delirium, and exaggerated tendon reflexes.
D) In mild hypothermia, with a core temperature less than 34-35°C, the patient has agitation, confusion, vigorous shivering, and hyperventilation.
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