A young adult client is brought into the emergency department with hypothermia. The nurse realizes that which of the following may have contributed to the condition in this client?
1. Alcohol intake
2. Walking outdoors in 30°Fweather
3. Not wearing a hat
4. Wearing light socks and tennis shoes
1. Alcohol intake
Rationale:
Alcohol causes peripheral vasodilation, which exposes the circulating bloodstream to more rapid cooling, resulting in a faster decrease in body temperature. The client's intake of alcohol contributed to the development of hypothermia. Skin freezes when the temperature drops to 14–24.8°F. Not wearing a hat and wearing light socks and tennis shoes may not have helped but did not cause the client to develop hypothermia.
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A nurse observes a certified nursing assistant (CNA) wearing one pair of gloves when taking vital signs on all assigned clients. What action should the nurse take immediately?
a. Ask the CNA to explain the rationale for this in a private conference. b. Ignore the behavior because the CNA is following agency procedure. c. Report the CNA to the charge nurse. d. Teach the CNA the correct procedure, stressing the rationale.
You are caring for a patient who is diagnosed with Raynaud's phenomenon. The nurse should plan interventions to address what nursing diagnosis?
A) Chronic pain B) Ineffective tissue perfusion C) Impaired skin integrity D) Risk for injury
Informed consent is not obtained when:
A) The researcher pays the subjects a stipend B) The researcher collects information covertly C) The risk/benefit ratio is low D) The study is not reviewed by an IRB
In teaching the pregnant adolescent about nutrition, the nurse should:
a. Emphasize the need to eliminate common teen snack foods because they are too high in fat and sodium. b. Determine the weight gain needed to meet adolescent growth and add 35 lb. c. Suggest that she not eat at fast-food restaurants to avoid foods of poor nutritional value. d. Realize that most adolescents are unwilling to make dietary changes during pregnancy.