22. A client, who had been playing golf in 110°F outside temperature, is admitted to an emergency department with hyperthermia. A nursing assessment would reveal:
Select all that apply.
22. A client, who had been playing golf in 110°F outside temperature, is admitted to an emergency department with hyperthermia. A nursing assessment would reveal:
Select all that apply.
. Absence of sweating.
. Decrease in body temperature.
. Increase in sweating.
. Increased blood pressure.
. Tachycardia.
. Flushed appearance.
Test-Taking Tip
Think heat stroke—a failure of the body's regulatory mechanism.
Content Area: Adult Health, Thermoregulatory; Integrated Process: Nursing Process, Assessment; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Medical Emergencies
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Answer 1 is correct because sweating decreases as heat exhaustion progresses to heat stroke. Answer 2 is incorrect because the body temperature is usually above 104°F. Answer 3 is incorrect because the skin may first be damp if the client has been active, then no perspiration. Answer 4 is incorrect because blood pressure decreases, and there is tachycardia and rapid respiratory rate—the symptoms of shock. Answer 5 is correct because the client is experiencing severe dehydration and will present with symptoms of shock. Answer 6 is correct because the client has lost the normal cooling mechanism of perspiration. The skin will be flushed and dry from the high internal body temperature.