A client comes to the emergency department with a temperature of 104°F. Which assessment findings should the nurse use to determine if this client is experiencing heat stroke?
1. Delirious
2. Pale and dizzy
3. Skin warm and flushed
4. No evidence of sweating
5. Had been playing tennis in the sun
Correct Answer: 1, 3, 4, 5
Rationale 1: Persons experiencing heat stroke may be delirious.
Rationale 2: Heat exhaustion is a result of excessive heat and dehydration. Signs of heat exhaustion include paleness and dizziness.
Rationale 3: Persons experiencing heat stroke generally have warm, flushed skin.
Rationale 4: Persons experiencing heat stroke often do not sweat.
Rationale 5: Persons experiencing heat stroke generally have been exercising in hot weather.
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