NCLEX-RN
Basic Adult Health Care NCLEX Heart Questions Questions
Extract:
The nurse in the emergency department (ED) is caring for a 62-year-old male client.
Item 2 of 6
Triage Note
1700:
• The client was brought to the ED after collapsing on a tennis court.
• Vital signs: BP 94/57, T 105° F (40.5° C), P 115, RR 26, Pulse oximetry 95% on room air. • The client is lethargic and confused. Skin is pale, and there is some perspiration on the forehead. Thready peripheral pulses, clear lung fields bilaterally, tachypnea, shallow respirations.
Question 1 of 5
For each client finding below, click to specify if the finding is consistent with the disease process of heat exhaustion or heat stroke. Each finding may support more than 1 disease process.
| Client Findings | Heat Exhaustion | Heat Stroke |
|---|---|---|
| Temperature 105° F (40.5° C) | ||
| Confusion | ||
| Perspiration | ||
| Tachycardia | ||
| Signs of dehydration | ||
| Hypotension |
Correct Answer: A,B,C,D,E,F
Rationale: A (Heat Stroke), B (Heat Stroke), C (Heat Exhaustion), D (Both), E (Both), F (Both). Temperature 104°F and confusion are hallmark signs of heat stroke. Perspiration is typical in heat exhaustion but absent in heat stroke. Tachycardia, dehydration, and hypotension occur in both conditions due to heat stress.
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Question 2 of 5
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Question 5 of 5
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