the nurse is caring for a 65 year old client and notes a temperature of 101f how does the nurse interpret this finding the nurse is caring for a 65 year old client and notes a temperature of 101f how does the nurse interpret this finding
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Nursing Elites

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. The nurse is caring for a 65-year-old client and notes a temperature of 101°F. How does the nurse interpret this finding?

Correct answer: Hyperthermia

Rationale: A temperature of 101°F is indicative of hyperthermia, which is an elevated body temperature. Hyperthermia is commonly associated with fever or environmental factors such as excessive heat exposure. Choice B, 'A cold environment,' is incorrect as hyperthermia refers to elevated body temperature, not a cold environment. Choice C, 'Normal,' is incorrect as a temperature of 101°F is above the normal range for body temperature. Choice D, 'Hypothermia,' is incorrect as hypothermia refers to a low body temperature, not an elevated one.

2. What is a chronic condition where the heart is unable to pump blood effectively, leading to fluid buildup in the lungs and other parts of the body?

Correct answer: A

Rationale: The correct answer is A: Heart failure. Heart failure is a chronic condition characterized by the heart's inability to pump blood effectively, resulting in fluid accumulation in the lungs and other body tissues. Myocardial infarction (choice B) refers to a heart attack caused by a blocked coronary artery, leading to damage of heart muscle tissue. Pericarditis (choice C) is the inflammation of the pericardium, the protective sac around the heart. Pulmonary edema (choice D) is a condition where fluid builds up in the lungs, often as a result of heart failure.

3. During a seizure, what is the primary intervention?

Correct answer: A

Rationale: The primary intervention during a seizure is to protect the patient from injury. This involves creating a safe environment by moving harmful objects away, cushioning the head, and staying with the patient until the seizure ends. Inserting an airway is only necessary if the patient's airway is obstructed, not routinely during a seizure. Elevating the head of the bed is not a priority during an active seizure as it won't affect the seizure's outcome. Withdrawing all pain medications is not a standard practice unless there are specific contraindications related to the seizure itself.

4. Dr. Faulkner believes that directly observable events, such as stimuli and responses, are the appropriate focus of the study of development. Dr. Faulkner probably follows the __________ perspective of development.

Correct answer: C

Rationale: Dr. Faulkner's focus on directly observable events, such as stimuli and responses, aligns with the behaviorist perspective of development. Behaviorism emphasizes the influence of the environment on individual behavior and learning, with a strong emphasis on observable actions rather than internal mental processes or stages of development. Choice A, psychosexual, is associated with Freud's theory focusing on stages of psychosexual development. Choice B, psychosocial, is linked to Erikson's theory of psychosocial development. Choice D, cognitive-developmental, is related to Piaget's theory emphasizing cognitive development stages.

5. Which of the following is a complication of compartment syndrome?

Correct answer: B

Rationale: The correct answer is B: Pain and tissue damage. Compartment syndrome occurs due to increased pressure within the muscle compartments, leading to pain and tissue damage. Hemorrhage (choice A) is not a typical complication of compartment syndrome. Increased limb function (choice C) is not a complication but rather a potential improvement if the condition is managed appropriately. Chronic kidney disease (choice D) is unrelated to compartment syndrome.

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