The nurse is caring for a patient who came to the emergency department with confusion and muscle cramps after working outside on a hot day.What is the priority action of the nurse?

A) Place the patient in a tub of iced water.
B) Take the patient's temperature and vital signs.
C) Remove fans to prevent premature chilling.
D) Apply a hyperthermia blanket to lower temperature slowly.

Question

Elizabeth Goodman · Accepted Answer

Final Answer : B, Explanation :  Assessment includes taking the patient's temperature.The nurse then uses that measurement to guide care of that patient.Placing the patient in a tub of iced water,removing fans to prevent premature chilling,and applying a hyperthermia blanket to lower temperature slowly are not assessments but interventions.Prolonged exposure to the sun or high environmental temperatures overwhelms the body's heat loss mechanisms.These conditions cause heatstroke,a dangerous heat emergency,defined as a body temperature of 40° C (104° F)or higher.Signs and symptoms of heatstroke include giddiness,confusion,delirium,excess thirst,nausea,muscle cramps,visual disturbances,and even incontinence.The most important sign of heatstroke is hot,dry skin.A heatstroke can be fatal.Cool the person quickly.Ways to cool include placing wet towels over the skin,placing the person in a tub of tepid (not iced)water or into a tepid shower,spraying the person with cool water from a garden hose,and placing oscillating fans in the room.Emergency medical treatment includes applying hypothermia blankets,giving intravenous (IV)fluids,and irrigating the stomach and lower bowel with cool solutions.

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