An 80-year-old woman is brought to the emergency department after ...

[JMatthes]

An 80-year-old woman is brought to the emergency department after being found unconscious in her garage sitting in her car. Which assessment finding is most concerning to the nurse?
 
  a. Temperature, 97.6 F; pulse, 98; and blood pressure, 110/60
  b. Oxygen (O2) saturation of 78
  c. Cherry red mucous membranes
  d. Cold extremities

Question 2

The emergency department nurse is attempting to revive an unconscious, shivering person with extreme hypothermia (rectal temperature of 94 F). The nurse should be most alarmed with which change?
 
  a. The patient's cold ears turn red.
  b. The patient stops shivering.
  c. The patient's hands clench.
  d. The patient's reflexes return.

[moormoney]

Answer to Question 1

C
The cherry red mucous membranes are classic signs of carbon monoxide poisoning; unfortunately, they are very late signs. The temperature, pulse, and blood pressure are within normal limits. An O2 saturation of 78 could be corrected if accurate, and O2 saturation measurements are inaccurate in cases of carbon monoxide poisoning. Cold extremities do not necessarily indicate an urgent problem.

Answer to Question 2

B
Cessation of shivering indicates that the body's homeostatic response to generate heat has ceased and the patient's condition is deteriorating. Clenching hands are an insignificant finding. Red-dened ears and returning reflexes would indicate warming.

[JMatthes]

Thank you

[moormoney]

No problemo