Chapter 30: Vital Signs (Body Temperature)

The registered nurse is teaching a nursing student about alterations in body temperature outside the normal range. Which statement by the nursing student indicates the need for further teaching?

*A. "Bluish discoloration of the skin is noticed in patients with elevated body temperature."* B. "Ice crystals that form inside the cells of the patients with frostbite may cause tissue damage." C. "Malignant hyperthermia is an inherited condition that results in uncontrollable heat production." D. "Patients who are on diuretic and amphetamine medication therapy are at a high risk of heatstroke." Rationale: Hypothermia is the condition in which the skin temperature drops below 34° C (or 93.2° F). The patient exhibits various signs, such as the bluish discoloration of the skin or cyanotic skin. Ice crystals formed inside the cells of the patients with frostbite may cause permanent circulatory damage or tissue damage. Malignant hyperthermia is a hereditary condition of uncontrolled heat production that occurs when susceptible people receive certain anesthetic drugs. Patients are at a risk of heatstroke when they are on medication therapy with certain drugs that decrease the ability of the body to lose heat, such as diuretics, amphetamines, and beta adrenergic receptor antagonists. Test-Taking Tip: Read carefully and answer the question asked; pay attention to specific details in the question. Pg. 491

A patient reports to the nurse increased body temperature in the evening and decreased body temperature in the morning. What does the nurse educate this patient about normal circadian rhythms? Select all that apply.

*A. "The highest body temperature occurs at around 4:00 pm."* *B. "The lowest body temperature occurs between 1:00 am and 4:00 am."* C. "There will be alterations in circadian rhythm due to age." *D. "A normal body temperature change in a 24-hour period is 0.5° C and 1° C."* E. "Temperature patterns automatically reverse within one week of beginning to work a night shift." Rationale: In a normal circadian rhythm, the normal body temperature is highest at around 4:00 pm and lowest between 1:00 am and 4:00 am. The temperature change during a 24-hour period is usually between 0.5° C and 1° C. The circadian temperature rhythm does not alter with age. In night-shift workers, the temperature pattern does not change automatically within one week of beginning the night shift. It takes up to 3 weeks for such a change to happen. Pg. 490

The nurse understands that antipyretic drugs reduce body temperature by either increasing heat loss or by interfering with the immune system. Which drugs reduce fever by increasing heat loss? Select all that apply.

*A. Acetaminophen* *B. Salicylates* *C. Indomethacin* *D. Ketorolac* E. Corticosteroids Rationale: The drugs that reduce fever by increasing heat loss include acetaminophen, salicylates, indomethacin, and ketorolac. Corticosteroids reduce fever by suppressing the immune system and masking the signs of infection. Pg. 496

A 10-year-old child is brought to the hospital with high fever and chills. The nurse records the vital signs and finds that her temperature is 104° F (40° C), blood pressure is 130/85 mm Hg, and pulse rate is 120/min. The fever remains mostly high but is interspersed with periods of normal body temperature. What measures should the nurse adopt to reduce fever in the patient? Select all that apply.

*A. Administer antipyretics as ordered.* B. Apply tepid sponge baths. *C. Use cooling blankets.* D. Apply ice packs to axillae and groin. *E. Administer meperidine as ordered.* Rationale: The measures used to reduce fever should be aimed at promoting heat loss. Antipyretics reduce fever by increasing heat loss. Blankets cooled by circulating water promote heat loss through conduction. Meperidine reduces shivering and prevents further increases in body temperature. Tepid sponge baths and ice packs induce shivering and may further increase body temperature. Pg. 496-497

On examination, the nurse finds that the patient's body temperature is high. What are the situations when the body temperature rises above the baseline? Select all that apply.

*A. After long-distance running* B. After taking a stroll in the park *C. During physical or emotional stress* *D. During the evening, maximum at 4:00 pm* E. During early morning from 1:00 am to 4:00 am Rationale: The body maintains a balance between heat production and heat loss. This is reflected by various temperature readings throughout the day. Exercise such as long-distance running, stress, and strong emotions can increase cellular activity, thus raising body temperature. Body temperature may increase as high as 1 degree Fahrenheit because of an increase in physical activity throughout the day and is at its peak at 4.00 pm; thereafter it decreases. Taking a stroll in the park does not raise body temperature because it does not cause physical exertion. For most people, body temperature is usually lowest in the morning because of a decrease in the basal metabolic rate related to inactivity during the night. Pg. 489-490

A 10-year-old child is brought to the hospital with high fever and chills. The nurse records the vital signs and finds that the temperature is 104° F, blood pressure is 130/85 mm Hg, and pulse rate is 120 beats/minute. The fever remains mostly high but is interspersed with periods of normal body temperature. What factors affect the body temperature of a patient? Select all that apply.

*A. Age* B. Race *C. Stress* D. Fasting *E. Hormonal changes* Rationale: Various factors affect body temperature, including the age of the patient. Temperatures recorded in infants, young adults, and older adults vary. Stress also increases body temperature. Hormonal changes seen in females during menopause and ovulation also may affect temperature. Race and fasting status have no effect on body temperature. Pg. 489-490

A patient presents with heat stroke. How does the nurse manage the treatment of the patient? Select all that apply.

*A. By using oscillating fans* B. By administering IV antibiotics *C. By removing excessive clothing* *D. By using hypothermia blankets* *E. By irrigating the stomach with cool solutions* Rationale: The first treatment for heat stroke includes the use of oscillating fans to promote conductive heat loss from the body, removing excessive clothing, and irrigating the stomach with cool solutions. Hypothermia blankets are helpful in reducing the body temperature of the patient having a heat stroke. Having a heatstroke does not indicate that the patient has an infection, thus the nurse should not be administering IV antibiotics to the patient. Pg. 497

The nurse is assessing a patient with a respiratory infection. Which signs indicate that the thermostatic set point is raised in the patient? Select all that apply.

*A. Chills* *B. Shivering* C. Sweating *D. Piloerection* E. Vasodilation Rationale: The events that occur during a rise of the thermostatic set point in response to pyrogens are chills, shivering, and piloerection. These responses are the heat-conserving mechanisms of the body. Sweating and vasodilation occur in response to a lowering of the thermostatic set point and not in response to a rise. Sweating and vasodilation are responsible for heat loss from the body. Test-Taking Tip: Did you remember the meaning of piloerection? Recall that pil(o) means hair, so piloerection is commonly called goose bumps. Pg. 490

A patient has developed a high fever due to a bacterial infection. What are the symptoms the nurse expects to find in the patient? Select all that apply.

*A. Confusion* *B. Increased metabolism* C. Decreased respiratory rate *D. Increased heart rate and angina* E. Salt and water retention Rationale: During fever, the oxygen demand on the body increases and patients are at risk of developing hypoxia, which may lead to confusion. There is increased metabolism in the body owing to removal of the disease-causing bacteria from the body. Because greater blood supply is required in response to increased metabolism, the workload of the heart increases during infection. This leads to an increased heart rate. With increased metabolism and an associated increase in oxygen consumption, such patients may develop angina due to hypoxia. During fever, patients are at risk of dehydration, not water retention. There is an increase in the respiratory rate to meet the oxygen demands of the body. Pg. 491

The nurse is assessing a patient who has just been rescued after falling into a frozen lake. The patient's body temperature has fallen below 93.2° F (34° C). Which signs should the nurse expect the patient to show? Select all that apply.

*A. Cyanosed skin* *B. Uncontrolled shivering* *C. Cardiac dysrhythmias* D. Increased blood pressure E. Increased respiratory rate Rationale: This is a typical case of accidental hypothermia in which the patient shows signs such as uncontrolled shivering and cyanosis; cardiac dysrhythmias may occur in later stages. The body may try to generate heat to counteract hypothermia by shivering. Hypothermia results in a decreased blood supply to the peripheral organs, resulting in cyanosis. Cardiac dysrhythmias may occur because the cells of the body cannot function at low temperatures. Blood pressure and respiratory rate tend to fall in hypothermia. Pg. 491

The nurse is assessing a patient who was brought to the hospital with a body temperature of 41.1° C (106° F). Which signs and symptoms would the nurse likely find in the patient? Select all that apply.

*A. Delirium* B. Cyanotic skin *C. Visual disturbances* *D. Increased heart rate* E. Increased blood pressure Rationale: Heat depresses the hypothalamic function. The condition of heatstroke is defined as a body temperature of 41.1° C (106° F) or more. It is a dangerous heat emergency with a high mortality rate. The common signs and symptoms of heatstroke include the patient showing a state of delirium, as well as disturbances related to vision. The heart rate would also be increased. If the patient is in a severe state of hypothermia, the patient shows cyanosis of skin. There would be a drop in the blood pressure—not an increase—if the patient has heatstroke. Pg. 491

The nurse is teaching the parents of a child suffering from a relapsing high fever about hypothermia blankets. Which information is true about hypothermia blankets? Select all that apply.

*A. Distal extremities of the body should be wrapped.* B. These blankets consist of coolant gels in between layers of lint. *C. Placing a bath towel between the skin and the hypothermic blanket is important.* *D. These blankets are cooled by circulating water delivered by motorized units.* E. The blankets should be used to cover the central areas of the body such as the chest. Rationale: Hypothermia blankets increase conductive heat loss and reduce fever. The hypothermia blanket should be wrapped on the distal extremities to reduce the risk of injury to the skin and tissue from hypothermia therapy. A bath towel should be placed between the hypothermic blanket and the patient to prevent injury to the skin. Hypothermia blankets are cooled by circulating water delivered by motorized units. Wrapping the patient's extremities reduces the incidence and intensity of shivering. Wrapping the central areas and keeping the peripheries exposed would cause shivering. Pg. 497

A patient reports a loss of sensation in the fingers and toes after being exposed to cold temperatures. Upon assessment, the nurse observes the injured area becoming white, waxy, and firm to the touch. What condition do these signs and symptoms likely indicate?

*A. Frostbite* B. Heatstroke C. Hypothermia D. Heat exhaustion Rationale: Frostbite occurs when the body is exposed to subnormal temperatures. Ice crystals form inside the cells, and permanent circulatory and tissue damage occurs. Areas particularly susceptible to frostbite are the earlobes, tip of the nose, fingers, and toes. The injured area becomes white, waxy, and firm to the touch. Heatstroke occurs due to prolonged exposure to the sun, or a high environmental temperature overwhelms the heat-loss mechanisms of the body; it is usually accompanied by uncontrolled shivering, loss of memory, and poor judgment. Heat loss during prolonged exposure to cold overwhelms the body's ability to produce heat, causing hypothermia. Heat exhaustion occurs when profuse diaphoresis results in excess water and electrolyte loss, caused mainly by environmental heat exposure. Pg. 491

A 56-year-old patient with diabetes admitted for community-acquired pneumonia has a temperature of 38.2° C (100.8° F) via the temporal artery. Which additional assessment data are needed in planning interventions for the patient's infection? Select all that apply.

*A. Heart rate* *B. Presence of diaphoresis* C. Smoking history *D. Respiratory rate* E. Recent bowel movement F. Blood pressure in right arm *G. Patient's normal temperature* H. Blood pressure in distal extremity Rationale: To plan interventions for this patient's infection the nurse would need to know the patient's heart rate, presence of diaphoresis, respiratory rate, and the patient's normal temperature. The patient's bowel movement and blood pressure are not data that are integral to planning this patient's care. Pg. 487, 491

The nurse is conducting a class on different temperature measurement sites. In which patients should the tympanic membrane be used as a site for temperature measurement? Select all that apply.

*A. In patients who do not mind the removal of their hearing aids* B. In patients with otitis media C. In patients who had surgery of the ear D. In patients with cerumen impaction *E. In patients complaining of tachypnea* Rationale: A tympanic thermometer is fast, safe, noninvasive, and can be used for patients complaining of tachypnea without affecting breathing. Hearing aids must be removed before measurement. Tympanic thermometers are not recommended for patients who have had a recent ear infection such as otitis media; using a tympanic thermometer may spread the infection and may measure inaccurately. Patients with cerumen impaction should not have their temperature measured through a tympanic thermometer, because it can give an erroneous reading. Surgery on the ear is a contraindication for use of the tympanic thermometer. Test-Taking Tip: Always consider patient safety and comfort when choosing your responses. For a patient who has otitis media, recently had ear surgery, or has cerumen impaction, using the tympanic membrane could be painful or even harmful. Thus, those are not correct responses. Pg. 493

The nurse is learning about different types of fevers. Which statements are true about relapsing fever? Select all that apply.

*A. It includes periods of febrile episodes and periods with acceptable temperature values.* *B. Febrile episodes and periods of normothermia are often longer than 24 hours.* C. It is typified by a constant body temperature continuously above 100.4° F (38° C) and has little fluctuation. D. It includes fever spikes interspersed with usual temperature levels. E. It includes fever spikes and falls without a return to normal temperature levels. Rationale: A relapsing fever is characterized by periods of febrile episodes and periods with acceptable temperature values. These episodes often last longer than 24 hours. A sustained body temperature continuously above 100.4° F (38° C) with little fluctuation is called a sustained fever. An intermittent fever is characterized by fever spikes interspersed with usual temperature levels. Fever spikes and falls without a return to normal temperature levels are found in remittent fever. Pg. 491

A registered nurse is asking the nursing student to list the mechanisms that would occur in a patient when the posterior hypothalamus senses that the body temperature is lower than the set point. Which mechanisms listed by the student indicate effective learning? Select all that apply.

*A. Muscle shivering* B. Excessive sweating *C. Narrowing of blood vessels* D. Inhibition of heat production *E. Voluntary muscle contraction* Rationale: The posterior hypothalamus senses if the body temperature drops below the set point, at which point the body then initiates heat-conservation mechanisms. Shivering is the mechanism that occurs when vasoconstriction is ineffective in preventing heat loss. Vasoconstriction, or narrowing of blood vessels, is a heat-conservation mechanism that reduces blood flow to the skin and extremities. Voluntary muscle contraction is a compensatory heat production mechanism. Excessive sweating and vasodilation are the heat loss mechanisms that are controlled by the anterior hypothalamus. Pg. 488

The nurse suspects a patient of having heatstroke. Which signs and symptoms should the nurse look for in the patient? Select all that apply.

*A. Nausea* B. Bradycardia *C. Excessive thirst* D. Cyanosed skin *E. Visual disturbances* Rationale: Heatstroke is a condition in which the body temperature is 104° F (40° C) or greater. It may happen due to imbalance in heat loss mechanisms of the body caused by prolonged exposure to the sun or a high environmental temperature. The signs and symptoms of heatstroke include nausea, excessive thirst, and visual disturbances. Bradycardia and cyanosed skin are symptoms of severe hypothermia. Pg. 491

The nurse is attending to a patient with fever. Which nursing interventions are appropriate when caring for this patient? Select all that apply.

*A. Provide fluids.* B. Administer routine antibiotics. *C. Instruct patient to limit physical activity.* D. Set the room temperature between 86° F (30° C) and 93° F (34° C). *E. Reduce the external covering of the patient's body enough so that the heat dissipates but not so much that the patient begins to shiver.* Rationale: Adequate fluids should be provided to compensate for the fluid loss due to sweating and hypermetabolism. Physical activities would further increase core body temperature; therefore, they should be avoided to minimize heat production. Reducing the external covering of the patient's body would help to dissipate heat and decrease body temperature. Antibiotics should not be administered unless the causative pyrogen has been identified. The room temperature should be set at a lower, comfortable temperature of around 70° F (21° C) to 80° F (27° C). Pg. 496

While performing rounds, the pediatrician finds that there is a temperature fluctuation in a neonate and orders the nurse to measure the temperature and note the values. Which sites for temperature measurement would the nurse most likely use? Select all that apply.

*A. Skin* B. Oral C. Rectal *D. Temporal artery* *E. Tympanic membrane* Rationale: The nurse can use the skin, temporal artery, and tympanic membrane for measuring the temperature in a newborn or neonate. Sites such as the oral cavity are not recommended for newborns, infants, and small children. The rectal site is usually not an acceptable site of temperature measurement for the routine checkup of vitals in newborns. Pg. 493

A patient presents to an emergency room with a high body temperature. Which nursing measures does the nurse implement to reduce the patient's body temperature? Select all that apply.

*A. Switch on a fan.* *B. Apply an ice pack.* C. Apply an aquathermia pad. *D. Bathe the patient with a cool cloth.* E. Cover the body with dark and closely woven clothes. Rationale: A fan promotes the loss of heat through convection. Heat loss through conduction can be encouraged by the application of ice packs and bathing the patient with a cool cloth. Aquathermia pads help the body gain heat through conduction; they do not promote heat loss. Covering the body with dark and closely woven clothes reduces heat lost from radiation; the clothes will not decrease the patient's body temperature. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. Pg. 496-497

A patient has a body temperature of 99° F. What temperature does the nurse record in Celsius? Record your answer using a whole number.

37° C Rationale: To convert Fahrenheit to Celsius, the Fahrenheit reading should be subtracted by 32, and then the result should be multiplied by 9/5. Applying this formula to 99° F, we get (99 - 32) × 5/9 = 37. Pg. 492

On examination, the nurse finds that a patient has a temperature of 104° Fahrenheit. What would the temperature be in Celsius? Record your answer using a whole number.

40° C Rationale: When it is necessary to convert temperature readings from Fahrenheit to Celsius, subtract 32 from the Fahrenheit reading and multiply the result by 5/9. Use the formula C = (F - 32) × 5/9, where C represents Celsius and F represents Fahrenheit. Thus, 104 - 32 is 72, multiplied by 5/9 = 40° C. Study Tip: Practice converting temperatures from Fahrenheit to Celsius and Celsius to Fahrenheit. You will need to memorize the formula. Pg. 492

A patient has a body temperature of 35A patient has a body temperature of 35° C. What temperature does the nurse record in Fahrenheit? Record your answer using a whole number.

95° F Rationale: To convert Celsius to Fahrenheit, the Celsius reading first should be multiplied by 9/5, and then add 32 to the product. Applying this formula to 35° C, we get (35 × 9/5) + 32 = 95. Test-Taking Tip: Although an on-screen calculator will be available for you when taking the NCLEX ®, you will need to remember the formula to convert Celsius to Fahrenheit (and Fahrenheit to Celsius). Pg. 492

An elderly patient has recently shifted to a residence located at a high altitude and finds it difficult to cope with extreme temperatures. The patient feels that there is a body system problem because the patient experiences more cold than other people do. The nurse explains to the patient that this is a normal response to aging. What is the rationale for this response? Select all that apply.

A. "Aging increases metabolism." *B. "Aging causes poor vasomotor control."* C. "Aging increases sweat gland activity." *D. "Aging reduces subcutaneous tissue."* *E. "Aging affects the temperature control mechanism."* Rationale: Elderly people have poor vasomotor control. There is inefficient vasomotor regulation in response to alterations in temperature. Fat and subcutaneous tissues play a major role in insulation. There is reduction of subcutaneous tissue in aging. The activity of the hypothalamus and thus the temperature control mechanism also deteriorates with aging. Metabolism and sweat gland activity decrease with aging, making the temperature control mechanism less effective. Pg. 489

An older adult with a history of cardiovascular disease is admitted to the emergency department in an unconscious state. Upon assessing the patient's vitals, the nurse observes a very high body temperature along with increased heart rate and nonreactive pupils. Which intervention would be correct for this patient?

A. Administering antibiotics therapy B. Placing heating pads next to the neck and head *C. Irrigating the stomach and lower bowel with cool solutions* D. Assessing the medication history of the patient to determine drug allergies Rationale: Heatstroke is a dangerous heat emergency with a high mortality rate. Patients at risk include young patients, older adults, and patients who have cardiovascular disease. If the condition progresses, the patient with heatstroke becomes unconscious, with fixed, nonreactive pupils. Permanent neurological damage occurs unless cooling measures are rapidly started. Irrigating the stomach and lower bowel with cool solutions helps reduce the high body temperatures. Administering antibiotic therapy may bee accurate for patients with fever caused by an infection, but not heatstroke. Placing heating pads next to the neck and head prevents heat loss and is an appropriate intervention in the patients with hypothermia. Heatstroke would not require assessing the patient's medical history. Test-Taking Tip: If the question asks for an immediate action or response, all of the answers may be correct, so base your selection on identified priorities for action. Pg. 497

Which statements accurately describe body temperature? Select all that apply.

A. Body temperature is highest at 6:00 AM. *B. Pulmonary artery catheters measure core temperatures.* C. The average oral temperature for healthy young adults is 35° C (95° F). D. The average core temperature in the older adult population is 37° C (98.6° F). *E. Temperature values are affected by the temperature measurement site.* Rationale: Invasive measurements of body temperatures with the help of pulmonary artery catheters are used to find core body temperatures. Temperature values differ depending on measurement site. The time of day also affects body temperature; body temperature is highest at 4:00 PM. For young, healthy adults, the average oral temperature is 37°C (98.6° F). In the older adult population, the average core temperature ranges from 35 to 36.1° C (95 to 97° F). Pg. 488

The nurse is attending to a patient who has a fever. The nurse informs the healthcare provider that the patient is in the plateau stage of fever. Which symptoms would have led the nurse to this conclusion? Select all that apply.

A. Chills B. Sweating C. Shivering *D. Feeling dry* *E. Feeling warm* Rationale: During the initiation phase of fever, the body temperature rises and the patient may experience chills, shiver, and may ask for blankets. During the plateau phase of a fever, the patient may feel dry and warm. If the new set point is overshot or the pyrogens are removed (e.g., destruction of bacteria by antibiotics), the third phase of a febrile episode occurs. The hypothalamus set point drops, initiating heat loss responses. The skin becomes warm and flushed because of vasodilation. Diaphoresis assists in evaporative heat loss. When the fever breaks, the patient becomes afebrile. Pg. 490

A woman experiences a rise in body temperature during ovulation. Which hormone is responsible for this?

A. Inhibin B. Estrogen *C. Progesterone* D. Luteinizing hormone Rationale: Ovulation is associated with the release of greater amounts of progesterone into circulation, which is responsible for raising body temperature. Inhibin, estrogen, and luteinizing hormone have no role in raising body temperature. Inhibin inhibits the synthesis and secretion of follicle-stimulating hormone. Estrogen is the female sex hormone responsible for development of secondary sexual characteristics in females and regulation of the menstrual cycle. Luteinizing hormone triggers the process of ovulation. Pg. 490

Which statement is true about body temperature?

A. It is the amount of heat produced by body processes. B. It is the amount of heat lost to the external environment. C. It is the sum of the amount of heat produced and the amount of heat lost. *D. It is the difference between the amount of heat produced and the amount of heat lost.* Rationale: Body temperature is the difference between the amount of heat produced by body processes and the amount of heat lost to the external environment. Body temperature is not the amount of heat produced by body processes or the amount of heat lost to the external environment, nor is it the sum of the amount of heat produced and the amount of heat lost. Pg. 488

The nurse in the pediatric intensive care unit is evaluating the vital signs of an infant born to an HIV-positive mother. The infant's temperature was high in previous readings. The blood reports of the infant are pending. What are the possible sites where temperature can be measured in this patient? Select all that apply.

A. Oral site B. Rectal site C. Axillary site *D. Temporal artery site* *E. Tympanic membrane site* Rationale: Various sites can be used to measure temperature in infants. In this case, the infant could be HIV positive so it is important to use sites where there is a low risk of exposure to body fluids for the nurse. There is a risk of exposure to body fluids in both oral and rectal sites, so these are not appropriate in this case. The tympanic membrane site can be used in this case because there is low risk of exposure to body fluids; there is also reduced infant handling and heat loss because measuring from the tympanic membrane site is a very rapid measurement (2 to 5 seconds). There is no risk of injury to the patient or nurse when measuring from the temporal artery site, so there is no risk of exposure to body fluids. The axillary site is not recommended for measuring temperature in infants and young children. Pg. 492

The nurse is reviewing the clinical data of 4 patients. Which patient is experiencing a remittent pattern of fever? Observations---------------------------------------Patient Body temp. of 38.6°C (101.4°F) throughout the day with little fluctuations-------------------------------------------A Body temp. above 39.7°C (103.4°F) throughout the day and 36.9°C (98.4°F) during the night--------------------------------------B Body temp. fluctuates between 39.7°C (103.4°F) and 38.7°C (101.6°F) for two days---------C Body temp. fluctuates between 101.3°F and 98.4°F every other day-------------------------D

A. Patient A B. Patient B *C. Patient C* D. Patient D Rationale: Fevers and fever patterns serve a diagnostic purpose. Fever patterns differ depending on the causative pyrogen. The increase or decrease in pyrogen activity results in fever spikes and declines at different times of the day. In a remittent fever pattern, temperature spikes and falls without returning to acceptable temperature levels as exemplified by patient C, whose temperature fluctuates between 39.7° C (103.4° F) and 38.7° C (101.6° F) for two days. Patient A with a body temperature of 100.4° F throughout the day with little fluctuation is experiencing a sustained fever. Patient B with a body temperature of 103.4° F throughout the day and 98.4° F during the night is showing signs of an intermittent fever pattern. Patient D with a body temperature fluctuating between 101.3° F and 98.4° F every other day is experiencing a relapsing fever. Test-Taking Tip: Chart/exhibit items present a situation and ask a question. A variety of objective and subjective information is presented about the patient in formats such as the medical record (e.g., laboratory test results, results of diagnostic procedures, progress notes, health care provider orders, medication administration record, health history), physical assessment data, and assistant/patient interactions. After analyzing the information presented, the test taker answers the question. These questions usually reflect the analyzing level of cognitive thinking. Pg. 491

The registered nurse is teaching a nursing student about interventions that should be performed for patients with fever to minimize heat production. Which interventions performed by the nursing student reflect effective learning? Select all that apply.

A. Providing 8 to 10 glasses of fluids per day B. Applying a damp cloth to the patient's forehead *C. Encouraging the patient to increase rest periods* D. Reducing external covering on the patient's body *E. Advising the patient to avoid turning and ambulating excessively* Rationale: Nursing interventions are important for patients who have fever. Excessive activity such as turning and ambulation increases oxygen demands and heat production; therefore, the nurse should advise the patient to limit such activities and increase rest periods. Providing 8 to 10 glasses of fluids is a safety requirement for increased metabolic rate. Reducing external covering on the patient would help maximize heat loss from the body. Application of a damp cloth to the patient's forehead promotes comfort but does not minimize heat production. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation. Pg. 496

A patient is admitted to a surgical unit after repair of a fractured left arm and left leg following a motor vehicle accident. An intravenous (IV) line is infusing in the right antecubital fossa, and pneumatic compression stockings are on the right lower leg. Oxygen is being administered via a simple face mask. Which sites should be used for obtaining the patient's blood pressure and temperature?

A. Right antecubital and oral *B. Right popliteal and temporal artery* C. Left antecubital and oral D. Left popliteal and temporal artery Rationale: The only extremity that does not have a compromised artery to auscultate for a blood pressure would be the right lower leg after the sequential device is removed. The oral site for temperature is contraindicated with face mask oxygen therapy. Pg. 493, 508

A patient is admitted to the hospital with high fever. The healthcare provider tells the nurse to administer a drug to decrease heat production in the patient. Which drug will most likely be prescribed to this patient?

A. Salicylates B. Indomethacin *C. Corticosteroids* D. Acetaminophen Rationale: Corticosteroids reduce heat production by interfering with the immune system. As a result, they bring down the temperature of the patient. Salicylates, indomethacin, and acetaminophen reduce the body temperature by promoting heat loss from the body. Pg. 496

Which factor is associated with a 0.5 to 1° C change in body temperature during a 24-hour period?

A. Stress B. Exercise C. Hormonal level *D. Circadian rhythm* Rationale: Temperature is one of the most stable rhythms in humans. Circadian body temperature rhythm normally changes 0.5 to 1° C (0.9 to 1.8° F) during a 24-hour period. Physical and emotional stress increases body temperature through hormonal and neural stimulation, but these stressors are not associated with a 0.5 to 1° C change in body temperature during a 24-hour period. Prolonged strenuous exercise, such as long-distance running, temporarily raises body temperature. Hormonal variations during the menstrual cycle cause body temperature fluctuations. Woman who have stopped menstruating often experience periods of hot flashes, in which skin temperature increases up to 4° C (7.2° F). Pg. 490

A 10-year-old child is brought to the hospital with high fever and chills. The nurse records the vital signs and finds that her temperature is 104° F (40° C), blood pressure is 130/85 mm Hg, and pulse rate is 120/min. The fever remains mostly high but is interspersed with periods of normal body temperature. What pattern of fever does the child have?

A. Sustained *B. Intermittent* C. Remittent D. Relapsing Rationale: Intermittent fever is characterized by spikes in temperature coupled with periods of normal temperature that occur at least once every 24 hours. In a sustained fever, the fever is continuous. In a remittent pattern, the fever spikes and falls without a return to normal temperature. In a relapsing fever, the fever lasts for more than 24 hours then alternates with a nonfebrile stage of 24 hours or more. Pg. 491

The nurse notes that the patient has been experiencing febrile episodes lasting more than 24 hours interrupted by periods of normal body temperature that also last than 24 hours. What does the nurse infer about the patient's fever pattern?

A. Sustained fever *B. Relapsing fever* C. Remittent fever D. Intermittent fever Rationale: When a patient shows periods of febrile episodes alternating with acceptable normal body temperatures, with both often lasting longer than 24 hours, it is called relapsing fever. Sustained fever is the body temperature that is constant, with a little fluctuation. When fever spikes and falls without returning to normal temperature, it is called remittent fever. Intermittent fever is associated with spikes interspersed with a return to normal temperature levels at least once within 24 hours. Pg. 491

The nurse is caring for an adult patient who is admitted to the hospital for fever and chills. The nurse repeatedly finds a temperature of 40° C (104° F) in the morning and 38.9° C (102°F) at night. What does the nurse infer about the fever pattern?

A. Sustained fever B. Relapsing fever *C. Remittent fever* D. Intermittent fever Rationale: Remittent fever often occurs with spikes of fever and falls without a return to acceptable temperature levels. The patient in this case has temperature spikes of 104° F (40° C), after which temperature falls to 102° F (38.9° C) but never returns to the normal range. Sustained fever is constant body temperature showing minimal fluctuations. Relapsing fever is associated with periods of febrile episodes and periods with acceptable temperature levels. Intermittent fever is associated with spikes of temperature interspersed with normal temperature levels. Pg. 489

While assessing a patient, the primary health care provider (PHP) finds that the patient is unconscious and the skin is cyanotic. What could be the possible cause?

A. The patient experienced severe diaphoresis. B. The patient's body is unable to promote heat loss. C. The patient has been exposed to sun for a prolonged time. *D. The patient has been exposed to cold temperatures for a prolonged time.* Rationale: Heat is lost when the patient's body is exposed to cold temperatures for a prolonged period of time; this condition is called hypothermia. The patient's body temperature, heart rate, respiratory rate, and blood pressure falls, causing the oxygen supply to the heart to become reduced, resulting in cyanosis. When the patient experiences severe sweating, body fluids are lost and the condition is known as heat exhaustion. An elevated body temperature related to the inability of the body to promote heat loss, or to reduce heat production, is called hyperthermia. Prolonged exposure to sun or higher temperature overwhelms the heat loss mechanisms in the patient and is known as heatstroke. In such instances, the patient becomes unconscious, with fixed and nonreactive pupils, and there would be an increase in heart rate, which would not cause cyanosis. Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly, because there usually is no pattern to the answers. Pg. 491

A patient has been brought to the emergency department (ED) after falling into a frozen lake. Which body parts should the nurse first assess for the presence of frostbite in the patient? Select all that apply.

A. Thighs B. Chest region *C. Earlobes* *D. Fingers* E. Shin of the leg Rationale: Peripherally exposed areas such as the earlobes, nose, toes, and fingers are more susceptible to developing frostbite because of poor circulation to those areas. Generally, one does not find frostbite in the central areas such as the thighs, chest, and shin of the leg because of the rich blood supply. Pg. 491

A patient was brought to the emergency department following a motor vehicle accident. The surgeon performs surgery and intentionally induces hypothermia. What does the nurse infer about the reason for inducing hypothermia? Select all that apply.

A. To restore fluid and electrolyte balances B. To reduce heat production in the patient *C. To reduce the metabolic demands of the body* *D. To reduce the oxygen requirements of the body* E. To overwhelm the heat-loss mechanisms of the body Rationale: Hypothermia occurs when the body is exposed to cold temperatures for a prolonged period of time. Occasionally hypothermia is intentionally induced during surgical or emergency procedures to reduce the metabolic demands of the body, as well as to reduce the body's oxygen supply requirements. When the patient experiences heat exhaustion, the primary intervention should be to cool the environment near the patient and restore fluids and electrolytes. Heat production should be reduced when the patient has hyperthermia. Hypothermia is not induced in the patient to overwhelm the heat-loss mechanisms, but is rather induced to reduce the metabolic and oxygen demands in the body. Pg. 491

A healthcare provider instructs the nurse to measure the body temperature of a patient. Which sites does the nurse choose to measure body temperature? Select all that apply.

A. Ulnar artery *B. Temporal artery* *C. Pulmonary artery* D. Dorsalis pedis artery *E. Tympanic membrane* Rationale: Core and surface body temperature can be measured at several sites. Intensive care units use the core temperatures of the pulmonary artery, esophagus, and urinary bladder. These measurements require the use of continuous invasive devices placed in body cavities or organs and continually display readings on an electronic monitor. Intermittent temperature measurements are obtained from the mouth, rectum, tympanic membrane, temporal artery, and axilla. The ulnar artery and dorsalis pedis artery are usually not employed for measuring the body temperature in a patient. These arteries are palpated to check for the pulse. Pg. 488

The nurse is giving a tepid sponge bath to a patient. The patient suddenly starts shivering during the bath. How does the nurse manage the shivering of the patient? Select all that apply.

A. Use cooling fans. *B. Administer meperidine or butorphanol.* C. Have patient bathe with alcohol-water solutions. *D. Wrap the patient's extremities.* E. Apply ice packs to axillae and groin areas. Rationale: Meperidine and butorphanol are medications that reduce shivering. Wrapping the patient's extremities provides warmth and reduces shivering. The use of cooling fans, bathing with alcohol-water solutions, and placing of ice packs on the axillae and groin areas will take heat away from the body and increase the shivering. Pg. 496-497