RNSG 1430 Thermoregulation, comfort, mobility

Which newborn would be a PRIORITY for the nurse to monitor for thermal regulation difficulties?

A preterm newborn with cyanotic hands, feet and tongue, and feeding poorly.

Which assessment finding can help the nurse differentiate between a child experiencing child neglect rather than child abuse?

A young child is admitted to the hospital with hypothermia because the child is inadequately dressed.

Proper positioning and therapeutic environment, avoiding sudden movement and reducing pain stimuli within the environment are what types of nonpharmacological interventions?

Basic comfort measures

The ability of a patient to move around in bed, including moving from lying to sitting and sitting to lying.

Bed positioning

This medication is taken by individuals who are unable to get enough calcium in their regular diet or who have a need for more calcium. The body needs calcium to make strong bones.

Calcium supplements

Cartilaginous tissue at fracture site

Callus

Rhythmic contractions of a muscle

Clonus

This medication is used to treat malignant hyperthermia, to reduce high fever related to anesthesia and surgery.

Dantrolene

One of the leading causes of low-back-pain, can be due to injury, fall or heavy lifting.

Degenerative disc disease

Occurs with tolerance, physical symptoms occur when opioid is discontinued

Dependence

Telling jokes, describing photos or playing games is what type of nonpharmacological intervention?

Distraction

A nurse is repositioning a patient who has physical limitations due to recent back surgery. How often would the nurse turn the patient in bed?

Every 2 hours The nurse would turn the patient in bed every two hours to avoid complications due to inactivity. The nurse would also include this activity in the patient plan of care.

Physical activity, tai chi and yoga are all what type of nonpharmacological interventions?

Exercise

True/False A person falling into cold water would result in heat loss through convection

False Conduction

True/False Crutches are used because they provide enough support for older client during ambulation and do not pose a risk for falls.

False Crutches are not used because they do not provide enough support for the client during ambulation and pose a risk for falls

A 2 inch wide belt with or without handles, that is fastened around a patients waist used to ensure stability when assisting patients to stand, ambulate or to transfer from bed to chair.

Gait belt

An intentional reduction of a patient's core temperature below 96.8 degrees F (36 degrees Celsius)

Induced hypothermia

A nurse assessing a postoperative patient who received a neuromuscular blocking (NMJ) agent during the procedure notes extreme muscle rigidity, pyrexia, and acidosis. What family history predisposed the patient to this event?

Malignant hyperthermia

Fill in the blank: _______ nociceptors are activated by excess pressure or a break in the skin Chemical FACES FLACC mechanical thermal

Mechanical

Hydraulic device with a sling used to move patients who cannot bear weight or have a medical condition that does not allow them to stand or assist with moving. It can be a portable device or permanently attached to the ceiling.

Mechanical lift

Which of the following manipulative therapies involves applying pressure and movement to stretch soft tissues?

Message Therapy Massage therapy involves applying pressure and movement to stretch and knead soft body tissues. Acupuncture involves pricking the skin or tissues with needles, used to alleviate pain and to treat various physical, mental, and emotional conditions. Aromatherapy is the use of aromatic plant extracts and essential oils in massage or baths. Sound healing or vibrational medicine, employs the vibrations of the human voice as well as objects that resonate -- tuning forks, gongs, Tibetan singing bowls -- to go beyond relaxation and stimulate healing.

biofeedback, meditation and mindfulness are all what type of nonpharmacological interventions?

Mind-body therapies

The ability of a patient to change and control body positions

Mobility

This medication is used to reverse symptoms of an opioid overdose

Naloxone

A position where the patient lies flat on their back

Supine positioning

Physical therapy and occupational therapy are all what type of nonpharmacological intervention?

Therapy

The action of a patient moving from one surface to another. this includes moving from a bed into a chair or moving from one chair to another.

Transferring

A position where the head of the bed is placed lower than the patients feet. this position is used in situations such as hypotension and medical emergencies because it helps promote venous return to major organs such as the brain and heart.

Trendelenburg position

Which of the following patients would be classified as having chronic pain?

a patient with rheumatoid arthritis Explanation: Chronic pain is pain that may be limited, intermittent, or persistent but that lasts beyond the normal healing period. Acute pain is generally rapid in onset and varies in intensity from mild to severe. After its underlying cause is resolved, acute pain disappears. It should end once healing occurs.

Movement away from the center of the body

abduction

Severe pain that erupts while a patient is already medicated with a long-acting painkiller.

breakthrough pain

List 3 common diagnostic tests to help determine the cause of a fever

chest x-ray urinalysis CBC

dispersion of heat by air currents

convection

Grating or cracking sound; may occur with movement

crepitus

Skin white, hard------> gangrene =________ frostbite

deep

Limp; without muscle tone

flaccid

Infection of the bone

osteomyelitis

Surgical cutting of bone

osteotomy

Lateral curving of the spine

scoliosis

List 3 other causes that may cause someone to have a fever

stress age exercise, hormones

Application of a pulling force to a part of the body

traction

True/False Pain is what the client says it is

true

A middle-aged client is complaining of acute joint pain to a nurse who is assessing the client's pain in a clinic. Which of the following questions related to pain assessment should the nurse ask the client?

"Does your pain level change after taking medications?" Explanation: The nurse should ask direct and specific questions about the nature of the pain and whether it changes with medication, as this helps the nurse to quickly gather objective data about the client's pain. The nurse should avoid asking irrelevant and closed-ended questions, such as whether the client's diet includes red meat and poultry products or whether the client has thought about the effects of his condition on the rest of his family. These types of questions do not add any value to pain assessment but could make the client feel more depressed and uncomfortable.

A nurse is performing discharge teaching for an elderly client diagnosed with osteoporosis. Which statement about home safety should the nurse include?

"Most falls among the elderly occur in the home. These clients should remove throw rugs and install bathroom grab bars." Falls in the home cause most injuries among the elderly. Elderly clients should take measures to decrease the clutter that can contribute to falls, such as removing objects such as throw rugs from the floor. Elderly clients should also install grab bars in the shower and next to the toilet. The threat of fire makes burglar bars on every window impractical.

The nurse is giving a talk to a woman's group on osteoporosis. What should the nurse tell this group concerning the development of osteoporosis?

"Osteoporosis involves a loss of bone mass." Osteoporosis is a metabolic bone disease characterized by a loss of mineralized bone mass, causing increased porosity of the skeleton and a greater susceptibility to fractures. The condition is most often related to the aging process and decreased estrogen levels in postmenopausal women.

The nursing instructor is teaching about osteoporosis and tells students that reduced physical activity can contribute to the loss of bone mass. What does the nurse tell the students is the rationale for this?

"Reduced physical activity increases the rate of bone loss, as mechanical forces are important stimuli for normal bone remodeling." Explanation: Reduced physical activity increases the rate of bone loss because mechanical forces are important stimuli for normal bone remodeling.

The 55-year-old client who is newly diagnosed with osteoarthritis of the hips asks the nurse why it hurts when walking. What is the nurse's best response?

"You have lost the padding in your joints and the friction causes pain." Explanation: Osteoarthritis is a common disorder as people age. It is a noninflammatory, progressive disorder of movable joints (particularly weight-bearing joints) characterized by the deterioration of articular cartilage and pain with motion. Cartilage acts as a shock absorber and provides a smooth surface that reduces friction between the moving parts of the joint. If the client experienced a fall and subsequent hip fracture, mobility would be more impaired. The client would have difficulty walking. Also, this does not address the client's question of why pain accompanies osteoarthritis. Although it is true that osteoarthritis is painful and common as people age, this response does not answer the client's question of why there is pain. Furthermore, while it is also true that loss of muscle tone is common as people age, it may cause weakness, but does not necessarily cause pain with walking.

Which of the following assessment tools will be most effective when assessing for pain in a four-year-old client?

A FACES scale Explanation: FACES scales are best for assessing pain in very young clients because these scales use pictures and short descriptive phrases. Although a numeric scale, a word scale, or a linear scale may be used, a child may find them difficult to understand.

This medication is a non-opioid analgesic and antipyretic

Acetaminophen

A patients joint receiving partial assistance in movement from an outside force

Active assist range of motion exercise

Movement of a joint by the individual performing the exercise

Active range of motion

Pain that is limited in duration and is associated with a specific cause. Last less than 6 months. Rapid onset, varies in intensity and duration.

Acute pain

A client fell from a ladder and broke his ankle and is being seen in the emergency department for severe ankle pain with swelling and limited range of motion. What type of pain does the nurse recognize the client is experiencing?

Acute pain Explanation: Acute pain is pain that is elicited by injury to body tissues and activation of nociceptive stimuli at the site of local tissue damage. It is generally of short duration and tends to resolve when the underlying pathologic process has resolved. Acute pain's purpose is to serve as a warning system. It alerts a person to the existence of actual or impending tissue damage and prompts a search for medical help.

Behavioral pattern characterized by need to take drug for psychic effects

Addiction

These drugs initially developed for an indication other than pain, but with analgesic properties for some painful conditions

Adjuvant drugs gabapentin, cyclobenzaprine, methocarbamol, baclofen

Medication that is not classified as an analgesic but has been found in clinical practice to have either an independent analgesic effect or additive analgesic properties when administered with opioids.

Adjuvent

The nurse is providing care to a group of clients in an acute care facility. The client MOST likely to prefer a room that is warm as well as wearing thermal blankets is the client who:

Aged 74 years.

This medication is used to prevent and treat certain types of bone loss in adults

Alendronate (Fosamax)

The ability of a patient to safely walk independently, with assistance from another person, or with an assistive device, such as a cane, walker or crutches.

Ambulation

Medication used to prevent or reduce fever

Antipyretic

Heat, and cold are what types of nonpharmacological interventions?

Application of heat and cold

Decrease in the size of the muscle

Atrophy

When the nurse is performing an assessment and finds no physical cause for a patient's pain, what should the nurse do when the patient continues to complain of pain?

Believe a patient when he or she states that pain is present. Explanation: The highly subjective nature of pain causes challenges in assessment and management; however, the patient's self-report is the undisputed standard for assessing the existence and intensity of pain (APS, 2008; McCaffery et al., 2011). Accepting and acting on the patient's report of pain are sometimes difficult. Because pain cannot be proved, the health care team is vulnerable to inaccurate or untruthful reports of pain. Clinicians are entitled to their personal doubts and opinions, but those doubts and opinions cannot be allowed to interfere with appropriate patient care.

The coordinated effort of muscles, bones and nervous system to maintain balance, posture and alignment during moving, transferring and repositioning patients.

Body mechanics

Fill in the blank: _________ nociceptors are activated by spices used in cooking such as capsaicin Chemical FACES FLACC mechanical thermal

Chemical

Constant or intermittent pain that is ongoing and persistent for longer than 6 months. Attributes to a specific cause or injury.

Chronic pain

A client comes to the outpatient clinic to receive cortisone injections in the neck for pain that has been occurring consistently for 8 months. What type of pain is this client experiencing?

Chronic pain Explanation: The characteristics of chronic pain, discomfort that lasts longer than 6 months, are almost totally opposite from those of acute pain. Referred pain is a term used to describe discomfort that is perceived in a general area of the body but not in the exact site where an organ is anatomically located. An example of neuropathic pain is phantom limb pain or phantom limb sensation, in which individuals with an amputated arm or leg perceive that the limb still exists and that sensation such as burning, itching, and deep pain are located in tissues that have been surgically removed. Acute pain is a discomfort that has a short duration (from a few seconds to less than 6 months). It is associated with tissue trauma, including surgery, or some other recent identifiable etiology.

Transfer of heat from one molecule to a molecule of lower temperature

Conduction

Acupuncture, acupressure, massage and transcutaneous electrical nerve stimulation are all what type of nonpharmacological interventions?

Cutaneous stimulation

Soft tissue swelling due to fluid accumulation

Edema

Losing heat through the conversion of water to gas. Causing heat loss through the energy required to vaporize moisture from respiratory tract, mucosa of mouth or skin.

Evaporation

Fill in the blank: Because newborns can suffer heat loss through _________ , immediately placing a hat on the and ______to______, with the mother will help keep the newborn warm. Cardiovascular old evaporation young skin-to-skin musculoskeletal

Evaporation skin-to-skin

Fill in the blank: The ______ scale is a visual tool for assessing pain with children and others who cannot quantify the severity of their pain on a scale of 0-10 Chemical FACES FLACC mechanical thermal

FACES

Fill in the blank: The _______ scale is a measurement used to assess pain for children between the ages of 2 months and 7 years or individuals who are unable to verbally communicate their pain. Chemical FACES FLACC mechanical thermal

FLACC

True/False Assisted range of motion exercises are encouraged to help delay or reverse osteoporosis.

False Assisted range of motion exercises are not weight bearing and do not help delay or reverse osteoporosis.

True/False Bone osdenitometry is considered the most accurate test for osteoporosis and for predicting a fracture and extent of disease

False Bone densitometry

True/False If a patient is having difficulty walking to the bathroom upon waking in the morning, consult occupational therapy for a assistive device such as a walker or cane to promote mobility

False Consult physical therapy

True/False Continuous passive motion machines can be used after hip surgery

False Continuous passive motion machines are not used after hip surgery

True/False Delaying giving a client pain medication will increase the chance of breakthrough pain and increase the clients pain tolerance.

False Delays in giving analgesics increases the chance of breakthrough pain and the subsequent anticipation of pain. It will not increase the tolerance.

True/False Intermittent ice pack and back rubs will promote muscle relaxation following osteoporotic fractures.

False Intermittent local heat and back rubs promote muscle relaxation following osteoporotic fractures

True/False Naltrexone is used to reverse the symptoms of an opioid narcotic.

False Nalaxone (Narcan) is used to reverse the symptoms of an opioid narcotic

True/False Following frostbite apply pressure to the affected site.

False No heavy clothing, blankets No massaging, rubbing No occlusive dressings on wounds

True/False Increased temperature is often the earliest sign when someone is developing malignant hyperthermia

False Tachycardia-HR greater than 150 bpm is often the earliest sign

True/False After receiving a hip prosthesis, the affected leg should be kept adducted. Mobility should be encouraged within safe limits.

False The affected leg should be kept abducted

True/False When using a PCA pump to control pain, the client controls the route and frequency and dosage of the medication administered. Family members are not allowed to push the button.

False the client controls the frequency of the IV analgesia. The client does not choose the dosage, the family members are not allowed to push the button, and the route of the medication is chose by the physician

A position where the patient is supine with the head of the bed placed at a 45 to 90 degree angle. The bed can be used to slightly flex the hips to help prevent the patient from migrating downwards in the bed.

Fowlers position

The ability of a person to move around in their environment, including walking, standing up from a chair, sitting down from standing and moving around in bed.

Functional mobility

You are caring for a patient who has been on bed rest. The primary care provider has just written a new order for the patient to sit in the chair three times a day. Which of the following actions will be most effective to transfer the patient safely into the chair?

Have the patient sit on the side of the bed for several minutes before moving to the chair. Having the patient sit at the side of the bed minimizes the risk for blood pressure changes (orthostatic hypotension) that can occur with position change.

Body temperature above 100 degrees F (37.8 degrees C)

Hyperthermia

A client in the operating room goes into malignant hyperthermia due to an abnormal reaction to the anesthetic. The nurse knows that the area of the brain that regulates body temperature is what?

Hypothalamus

Body temperature below 97 degrees F ( 36.1 degrees Celsius)

Hypothermia

Heat loss by evaporation from the skin

Insensible heat loss

The amount of body fluid lost daily that is not easily measured. For example sweat.

Insensible water loss

How can the nurse determine that a client's pain is characteristic of acute pain?

It is associated with a specific injury. Explanation: Pain often is described as being acute or chronic (persistent) (Pasero & Portenoy, 2011). Acute pain differs from chronic pain primarily in its duration. For example, tissue damage as a result of surgery, trauma, or burns produces acute pain, which is expected to have a relatively short duration and resolve with normal healing. Chronic pain is subcategorized as being of cancer or noncancer origin and can be time limited (e.g., may resolve within months) or persist throughout the course of a person's life.

Increase in the convex curvature of the thoracic spine

Kyphosis

A position where the patient lies on one side of the body with the top leg over the bottom leg. This position helps relieve pressure on the coccyx.

Lateral positioning

The nurse would expect which of the following age-related change of the musculoskeletal system?

Loss of bone mass Age-related changes include gradual, progressive loss of bone mass after age 30 years, decreased elasticity of tendons, thinning of intervertebral discs, and muscle atrophy.

An inherited severe reaction to certain drugs used for anesthesia causing a rapid rise in body temperature, tachycardia, hypertension and increased muscle contractions

Malignant Hypertension

These medications work peripherally and are used to treat mild to moderate pain or in combination with opioids for moderate to severe pain.

NSAIDs Celecoxib, ibuprofen

Pain caused by a lesion or disease of the somatosensory nervous systems that is typically described by patients as burning or like pins and needles.

Neuropathic pain

Normal body temperature 97.7 degrees F-98.9 degrees F (36.6-37.2 degrees celcius)

Normothermia

Which of the following pain assessment tools is most commonly used in adults?

Numeric scale Explanation: A numeric scale is commonly used when assessing adults. Children as young as three years of age can use a FACES scale.

What term refers to the time the pain began?

Onset Explanation: Onset is the time the pain began. Duration is the time span of the pain. Intensity is the magnitude of the pain. Quality is the sensory experience and the degree of suffering.

Low blood pressure that occurs when a patient changes position from lying to sitting and sitting to standing that causes symptoms of dizziness or light headedness.

Orthostatic hypotension

Degenerative disease of the bone characterized by reduced mass

Osteoporosis

What is the priority action for a client suffering Hypothermia?

Oxygen/airway attach cardiac monitor anticipate defibrillation

Abnormal sensation of tingling and numbness

Paresthesia

Movement applied to a joint solely by another person or a passive motion machine

Passive range of motion exercises

A method of pain management that allows hospitalized patients with severe pain to safely self-administer opioid medications using a programmed pump according to their level of discomfort.

Patient-Controlled Analgesia (PCA)

Withdrawal symptoms that occur when chronic pain medication is suddenly reduced or stopped because of physiological adaptations that occur from chronic exposure to the medication.

Physical dependence

Technical term for what happens when your hair stands up when you are cold, scared, or excited (goosebumps)

Piloerection

A nurse is caring for a 5-hour-old newborn. The primary care provider has asked the nurse to maintain the newborns temperature between 97.7 degrees Fahrenheit and 99.5 degrees Fahrenheit (36.5-37.5 degrees celcius). Which nursing intervention would be the BEST approach to maintaining the temperature within the recommended range?

Place the newborn skin-to-skin (kangaroo care) with the mother.

A position where the patient lies on their stomach with their head turned to the side

Prone position

Hyperthermia, fever where body temperature is above usual range

Pyrexia

Transfer of heat from the surface of one object to the surface of another

Radiation

Activities aimed to facilitate movement of specific joints and promote mobility of extremities.

Range of motion ROM exercises

A nurse has an order to take the core temperature of a client. At which site would a core body temperature be measured?

Rectal

Rhythmic breathing, meditation, prayer, imagery and music therapy is what type of nonpharmacological intervention?

Relaxation

A position where the head of the bed is placed at a 30-45 degree angle. the patients hips may or may not be flexed.

Semi-fowlers position

Give 3 assessment findings that would indicate hypothermia.

Shivering, chills, low oxygen saturation, sub normal temperature

A patient is receiving ongoing nursing care for the treatment of Parkinson's disease. When assessing this patient's gait, what finding is most closely associated with this health problem?

Shuffling Gait A variety of neurologic conditions are associated with abnormal gaits, such as a spastic hemiparesis gait (stroke), steppage gait (lower motor neuron disease), and shuffling gait (Parkinson's disease). A rapid gait is not associated with Parkinson's disease.

What organ is the primary site of heat loss in the body?

Skin

Type of nociceptive pain that is also referred to as skin pain, tissue pain, joint or muscle pain.

Somatic pain

The operating room nurse is taking a male patient into the OR when the patient informs the operating nurse that his grandmother spiked a 104 degree temperature in the operating room and nearly died 15 years ago. the nurse knows that the anesthetist is planning to use a volatile liquid as part of the anesthetic. What relevance is this information regarding the patient?

The patient may be at risk for developing malignant hyperthermia.

Fill in the blank: ______ nociceptors are activated by heat or cold. Chemical FACES FLACC mechanical thermal

Thermal

Which is an accurate rationale for why older adults are more susceptible to serious infections?

They have less efficient defense mechanisms

A reduced response to pain medication when the same dose of a drug has been give repeatedly, requiring a higher dose of the drug to achieve the same level of response.

Tolerance

True/False Addiction is characterized by several symptoms, such as the inability to consistently abstain from a substance, impaired behavioral control, cravings, diminished recognition of significant problems with ones behaviors and interpersonal relationships and a dysfunctional emotional response.

True

True/False Collaboration between the nurse, client and family members, is important to prevent injury when discharging patient home following total hip replacement surgery.

True

True/False Elderly patients often do not present with a temperature in the presence of an infection

True

True/False Fever can cause dehydration

True

True/False It is important that the patient be able to transfer independently prior to discharge to reduce the risk of injury

True

True/False Limited range of motion may lead to disease, resulting in impaired mobility

True

True/False Neonates born prematurely are at most risk of developing complications due to poor thermoregulation caused by lack of brown fat in their body

True

True/False Pain management pose special challenges for older clients. due to liver and renal changes, medication clearance is prolonged which can lead to toxicity.

True

True/False Pain must be controlled for a client to be willing to participate in physical activity

True

True/False Place extremities affected by frostbite in a circulating bath with water temperature between 98.6-104 degrees F for 20-30 minute spans

True

True/False Regular ROM exercises help to maintain joint function and decrease pain with mobility

True

Pain from body organs

Visceral pain

Movement toward the center of the body

adduction

Medication used to relieve pain

analgesics

The inability to sweat normally

anhidrosis

Lotions, moisturizing creams and avoiding strong smells are all what type of nonpharmacological intervention?

aroma therapy

Inflammation of a joint

arthritis

an object or piece of equipment designed to help a patient with activities of daily living, such as walker, cane, gait belt, or mechanical lift.

assistive device

Fill in the blank: The initial symptoms of malignant hyperthermia are related to _______ and _______ activity. Cardiovascular old evaporation young skin-to-skin musculoskeletal

cardiovascular musculoskeletal

The deterioration of body systems as a result of inactivity

disuse syndrome

Extremely high body temperature

hyperpyrexia

ropelike bundles of collagen fibrils connecting bones

ligament

Increase in concave curvature of the lumbar spine

lordosis

These medications are used to treat moderate to severe pain, work on central nervous system to block pain perception.

opioid analgesics morphine, hydromorphone, hydrocodone, meperidine

An unpleasant sensory and emotional experience associated with or resembling what associated with actual or potential tissue damage. Most common reason for seeking health care. the fifth vital sign.

pain

Pain perceived at a location other than the site of the painful stimulus. for example pain from retained gas in the colon can cause pain to be perceived in the colon

referred pain

The nurse is assisting a client to ambulate following knee surgery. What is a key concern when assisting clients with activity?

safety When moving a client, the nurse's key concerns are safety and client comfort. Privacy should be provided, as with any other nursing action, but this is not a key concern. Assisting a client with activity strengthens the nurse-client relationship. Confidentiality is not a major concern with activity.

Name 3 interventions the nurse should implement when malignant hyperthermia is suspected.

stay with the patient notify the dr and anesthesiologist remove extra blankets get order for dantrolene

blue skin, mottled or waxy yellow describes __________ frostbite

superficial

Cord of fibrous tissue connecting muscle to bone

tendon

Of the following individuals, who can best determine the experience of pain?

the person who has the pain Explanation: According to McCaffery, an expert on pain, "Pain is whatever the experiencing person says it is, existing whenever he (or she) says it does." The only one who can be a real authority on whether and how a person experiences pain is that individual.

A sensation of dizziness as if the room is spinning

vertigo

Frostbite rewarming priorities

warm water soaks, elevate affected extremities after rewarming, provide analgesic pain.

Fill in the blank: The very _______ and the very _______ are at most risk for problems with regulating body temperatures. Cardiovascular old evaporation young skin-to-skin musculoskeletal

young old