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Basic Adult Health Care NCLEX Questions Questions

Extract:

The nurse in the emergency department (ED) is caring for a 62-year-old male client.
Item 3 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

The client is at highest risk for developing ……………..

Correct Answer: B

Rationale: The client's severe hyperthermia, hypotension, tachycardia, and confusion suggest heat stroke, which can lead to multiple organ dysfunction due to systemic inflammation and hypoperfusion. Stroke (
A), myocardial infarction (
C), and respiratory acidosis (
D) are less directly associated with heat stroke complications.

Extract:


Question 2 of 5

Correct Answer:

Rationale:

Question 3 of 5

Correct Answer:

Rationale:

Question 4 of 5

Correct Answer:

Rationale:

Question 5 of 5

Correct Answer:

Rationale:

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