On a hot humid day, an emergency department nurse is caring for a ...

[tiffannnnyyyyyy]

On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 104.1  F (40.1  C), pulse 132 beats/min, respirations 26 breaths/min, blood pressure 106/66 mm Hg. Which action should the nurs
 
  a. Encourage the client to drink cool water or sports drinks.
  b. Start an intravenous line and infuse 0.9 saline solution.
  c. Administer acetaminophen (Tylenol) 650 mg orally.
  d. Encourage rest and re-assess in 15 minutes.

Question 2

A nurse prepares to discharge an older adult client home from the emergency department (ED). Which actions should the nurse take to prevent future ED visits? (Select all that apply.)
 
  a. Provide medical supplies to the family.
  b. Consult a home health agency.
  c. Encourage participation in community activities.
  d. Screen for depression and suicide.
  e. Complete a functional assessment.

[blfontai]

Answer to Question 1

ANS: B
The client demonstrates signs of heat stroke. This is a medical emergency and priority care includes oxygen therapy, IV infusion with 0.9 saline solution, insertion of a urinary catheter, and aggressive interventions to cool the client, including external cooling and internal cooling methods. Oral hydration would not be appropriate for a client who has symptoms of heat stroke because oral fluids would not provide necessary rapid rehydration, and the confused client would be at risk for aspiration. Acetaminophen would not decrease this client's temperature or improve the client's symptoms. The client needs immediate medical treatment; therefore, rest and re-assessing in 15 minutes is inappropriate.

Answer to Question 2

ANS: D, E
Due to the high rate of suicide among older adults, a nurse should assess all older adults for depression and suicide. The nurse should also screen older adults for functional assessment, cognitive assessment, and risk for falls to prevent future ED visits.

[tiffannnnyyyyyy]

Excellent

[scottmt]

TYSM