Thermoregulation
In order to prevent recurrent vasospastic episodes with Raynaud's phenomenon, the nurse should instruct the client to: a) Keep the hands and feet elevated as much as possible. b) Increase coffee intake to 2 cups per day. c) Wear gloves when obtaining food from the refrigerator. d) Use a vibrating massage device on the hands.
C. Wear gloves when obtaining food from the refrigerator Loose warm clothing should be worn to protect from the cold. Wearing gloves when handling cold objects will help prevent vasospasms. Vibrating equipment and typing contribute to vasospasm. Tobacco and caffeine should be avoided. Elevation will decrease arterial perfusion during vasospasms.
A toddler hospitalized with nephrotic syndrome has marked dependent edema and hypoalbuminemia. His urine is frothy. When assessing the child's vital signs, the nurse should report which finding to the primary care provider? a) Body temperature of 102.8° F (39.3° C). b) Respiratory rate of 28 breaths/minute. c) Blood pressure of 80/45 mm Hg. d) Pulse rate of 85 beats/minute.
A. Body temperature of 102.8° F (39.3° C). Temperature of 102.8° F (39.3° C) is elevated, suggesting an infection. The nurse should notify the primary care provider. The child is displaying signs and symptoms of nephrotic syndrome. With this disorder, blood pressure is characteristically normal or slightly low. The other vital signs are likely to be normal unless edema causes respiratory distress and respirations increase and become labored. The blood pressure reading, heart rate and respiratory rate here are within the normal range for a toddler. A pulse rate of 85 beats/minute is normal for a toddler. In nephrotic syndrome, the pulse rate would be normal unless other problems arise. A respiratory rate of 28 is normal for a toddler. In nephrotic syndrome, the respiratory rate would be normal unless edema causes respiratory distress and the respirations increase and become labored.
An adolescent is on the football team and practices in the morning and afternoon before school starts for the year. The temperature on the field has been high. The school nurse has been called to the practice field because the adolescent is now reporting that he has muscle cramps, nausea, and dizziness. Which of the following actions should the school nurse do first? a) Move the adolescent to a cool environment. b) Have the adolescent go to the swimming pool. c) Take the adolescent's temperature. d) Administer cold water with ice cubes.
A. Move the adolescent to a cool environment. The adolescent is most likely experiencing heat exhaustion or heat collapse, which are common after vigorous exercise in a hot environment. Symptoms result from loss of fluids and include nausea, vomiting, dizziness, headache, and thirst. Treatment consists of moving the adolescent to a cool environment and giving cool liquids. Cool liquids are easier to drink than cold liquids. Taking the adolescent's temperature would be appropriate once these actions have been completed. However, the adolescent's temperature is likely to be normal or only mildly elevated. The water in a swimming pool would be too cool, possibly causing the adolescent to shiver and thus raising his temperature
Two hours ago, a neonate at 38 weeks' gestation and weighing 3,175 g (7 lb) was born to a primiparous client who tested positive for beta-hemolytic Streptococcus. Which of the following would alert the nurse to notify the primary health care provider? a) Temperature instability. b) Alkalosis. c) Positive Babinski's reflex. d) Increased muscle tone.
A. Temperature instability. The neonate is at high risk for sepsis due to exposure to the mother's infection. Temperature instability in a neonate at 38 weeks' gestation is an early sign of sepsis. Other signs include tachycardia, decreased muscle tone, acidosis, apnea, respiratory distress, hypotension, poor feeding behaviors, vomiting, and diarrhea. Late signs of infection include jaundice, seizures, enlarged liver and spleen, respiratory failure, and shock. Alkalosis is not typically seen in neonates who develop sepsis. Acidosis and respiratory distress may develop unless treatment such as antibiotics is started. A positive Babinski's reflex is a normal finding and does not need to be reported.
When assessing a neonate's temperature with a disposable digital thermometer, in which of the following locations should the nurse place the thermometer? a) Into the neonate's rectum. b) Under the neonate's arm. c) Under the neonate's tongue. d) Into the neonate's ear.
B. Under the neonate's arm. The correct method of assessing a neonate's temperature is to place the thermometer under the neonate's arm for an axillary reading. The oral route is not appropriate for obtaining the temperature in a neonate because the neonate is unable to close the mouth around the thermometer, thus leading to an inaccurate reading. Additionally, inserting a thermometer into a neonate's mouth may cause trauma to delicate tissues. Rectal temperatures are to be avoided in neonates because of the risk of injury to or perforation of the delicate rectal mucosa. Only a specialized tympanic membrane device should be used to obtain a temperature reading via the ear. Inserting a disposable digital thermometer into the neonate's ear may cause trauma to the delicate tissues.
A child is admitted to the hospital with a febrile seizure. The nurse should: a) Place a padded tongue blade at the bedside. b) Keep the child supine. c) Place the child in isolation. d) Keep the room temperature low and bedclothes to a minimum.
D. Keep the room temperature low and bedclothes to a minimum. One nursing goal for a child with febrile seizures is to maintain the child's temperature at a level low enough to prevent recurrence of seizures. Decreasing the environmental temperature and removing excess clothing and blankets will help decrease the child's temperature. There is no reason to keep the child supine; a side-lying position would be acceptable and help decrease intracranial pressure. A febrile seizure, though, results from abnormal electrical activity in the brain due to elevated body temperature. Isolation precautions are not necessary unless the child has a condition that warrants such an isolation. Using a tongue blade to separate the teeth in the upper jaw from the lower jaw in an attempt to prevent the child from biting the tongue has proven to be ineffective and may result in broken teeth.
The nurse is caring for a client who had an open cholecystectomy 24 hours ago. The client's vital signs have been stable over the last 24 hours, with the most recent temperature 37 degrees Celsius (98.6 F), blood pressure (BP) 118/76, respiratory rate (RR) 16 per minute, and heart rate (HR) 78 beats per minute. Now, however, the vital signs are changing. Which of the following indicates that the nurse should contact the physician? a) Temperature 36.4 degrees Celsius (97.5 F), BP 98/64, HR 98 beats per minute, RR 18 per minute. b) Temperature 37.5 degrees Celsius (99.5 F), BP 126/80, HR 58 beats per minute, RR 16 per minute. c) Temperature 38.2 degrees Celsius (100.7 F), BP 118/68, HR 84 beats per minute, RR 20 per minute. d) Temperature 38.8 degrees Celsius (101.8 F), BP 140/86, HR 94 beats per minute, RR 24 per minute.
D. Temperature 38.8 degrees Celsius (101.8 F), BP 140/86, HR 94 beats per minute, RR 24 per minute. This client is exhibiting three of four signs of systemic inflammatory response syndrome (SIRS): temperature greater than 38 degrees Celsius (or less than 36 degrees Celsius), heart rate greater than 90 beats per minute, and respiratory rate greater than 20 breaths per minute. The fourth indicator is an abnormal white blood cell count (> 12,000 [12 X 109/L], < 4000 [4 X 109/L] or >10% [0.1 X 109/L] bands). At least two of these variables are required to define SIRS.
During the initial assessment, the nurse notes that the neonate's hands and feet appear blue while the neonate's torso appears pale pink. Which of the following should the nurse do next? a) Keep the neonate in an isolation incubator for at least 2 hours. b) Report the neonate's cyanosis to the primary care provider promptly. c) Ask the mother to massage the neonate's hands and feet. d) Wrap the neonate in a warm blanket.
D. Wrap the neonate in a warm blanket. The neonate is demonstrating acrocyanosis, a normal finding evidenced by bluish hands and feet due to the neonate being cold or poor perfusion of the blood to the periphery of the body. The most appropriate action is to wrap the neonate in a warm blanket or place the neonate under a radiant warmer. Massaging the extremities is inappropriate because it will not help to improve the circulation. Keeping the neonate in an isolation incubator is not warranted because acrocyanosis is not an infection but rather a manifestation of the neonate's sluggish peripheral circulation. Because acrocyanosis is a normal finding, notifying the primary care provider is not necessary
A client in the postanesthesia care unit is being actively rewarmed with an external warming device. How often should the nurse monitor the client's body temperature? a) Every 15 minutes. b) Every 20 minutes. c) Every 5 minutes. d) Every 10 minutes.
A. Every 15 minutes. In order to prevent burns, the nurse should assess the client's temperature every 15 minutes when using an external warming device.
A healthy neonate was just born in stable condition. In addition to drying the infant, what is the preferred method to prevent heat loss? a) Placing the infant skin-to-skin on the mother. b) Wrapping the infant in warmer blankets. c) Applying a knit hat. d) Placing the infant under a radiant warmer.
A. Placing the infant skin-to-skin on the mother. Placing an infant on a mother's bare chest or abdomen facilitates transition to extrauterine life and is the preferred method of thermoregulation for stable infants. A radiant warmer should be used if an infant is unstable and needs medical intervention. Blankets may be placed over a newborn and mom's chest. A hat may be added to prevent heat loss from the head, but these methods are supplemental to skin-to-skin care.
A client with schizophrenia started risperidone 2 weeks ago. Today, he tells the nurse he feels like he has the flu. The nurse's assessment reveals the following: temperature 104.4° F (40.2° C), respirations 24 breaths/minute, blood pressure 130/102 mm Hg, pulse rate 120 beats/minute. The nurse also notes muscle stiffness and pain, excessive sweating and salivation, and changes in mental status. The nurse suspects the client is experiencing: a) neuroleptic malignant syndrome. b) septicemia. c) the flu. d) malignant hyperthermia.
A. neuroleptic malignant syndrome. Neuroleptic malignant syndrome is a rare but potentially life-threatening reaction to an antipsychotic or neuroleptic. The cardinal symptom is a high temperature. Other commonly observed symptoms include altered mental status and autonomic dysfunction. Although fever may be present with the flu, it doesn't normally cause altered mental status or autonomic dysfunction. Malignant hyperthermia is a complication associated with general anesthesia. These findings don't suggest the client has septicemia. Findings in septicemia include severe hypotension, fever, tachycardia, and a history of a recent infection.
A nurse determines that a client is in false labor. After obtaining discharge orders, the nurse provides discharge teaching to the client. Which instruction is most appropriate at this time? a) "Maintain a supine position to promote rest." b) "Return to the facility if fever occurs." c) "Drink coffee or tea to maintain hydration." d) "Apply cold compresses to relieve discomfort."
B. "Return to the facility if fever occurs." The nurse should instruct a client in false labor to return to the health care facility if she develops signs or symptoms of infection, such as a fever; if her membranes rupture; if vaginal bleeding occurs; or if her contractions become more intense. The nurse should suggest warm milk or herbal tea, which promote relaxation and rest, instead of coffee or caffeinated tea. Taking a warm tub bath or shower — not applying cold compresses — helps relieve discomfort. A semi-upright position with pillows placed under the client's knees promotes rest.
The nurse is assessing a client with anemia. In order to plan nursing care, the nurse should focus the assessment on which of the following? a) Nausea. b) Cold intolerance. c) Bradycardia. d) Decreased salivation.
B. Cold intolerance. Cold intolerance may be associated with anemia because of the diminished oxygen supply to the peripheral circulation. Decreased salivation is not necessarily associated with anemia. Tachycardia may be expected in severe anemia. Clients with anemia are usually not nauseated.
A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to: a) increase the dose of muscle relaxants. b) rest in an air-conditioned room. c) avoid naps during the day. d) take a hot bath.
B. rest in an air-conditioned room. Fatigue is a common symptom in clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, ordered to reduce spasticity, can cause drowsiness and fatigue. Frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with MS include treating depression, using occupational therapy to learn energy-conservation techniques, and reducing spasticity.
A nurse is assessing a 1-hour-old neonate in the special care nursery. Which assessment finding indicates a metabolic response to cold stress? a) Hypertension b) Hyperglycemia c) Hypoglycemia d) Arrhythmia
C. Hypoglycemia Hypoglycemia, not hyperglycemia, occurs as a result of cold stress. When a neonate is exposed to a cold environment his metabolic rate increases as his body attempts to warm itself. The increase in metabolic rate causes glucose consumption resulting in hypoglycemia. Arrhythmia and hypertension are associated with cardiopulmonary problems.
A primigravid client at 30 weeks' gestation has been admitted to the hospital with premature rupture of the membranes without contractions. Her cervix is 2 cm dilated and 50% effaced. The nurse should next assess the client's: a) Degree of discomfort. b) Red blood cell count. c) Urinary output. d) Temperature.
D. Temperature. Premature rupture of the membranes is commonly associated with chorioamnionitis, or an infection. A priority assessment for the nurse to make is to document the client's temperature every 2 to 4 hours. Temperature elevation may indicate an infection. Lethargy and an elevated white blood cell count also indicate an infection. The red blood cell count would provide information related to anemia, not infection. The client is not in labor. Therefore, assessing the degree of discomfort is not a priority at this time. Urinary output is not a reliable indicator of an infection such as chorioamnionitis.
A client experiencing alcohol withdrawal exhibits tremors, diaphoresis, and hyperactivity. Blood pressure is 190/87 mm Hg and pulse is 92 bpm. Which of the following medications should the nurse expect to administer? a) Haloperidol b) Benztropine c) Naloxone d) Lorazepam
D. Lorazepam The nurse would most likely administer a benzodiazepine, such as lorazepam, to the client who is experiencing symptoms of alcohol withdrawal. The benzodiazepine substitutes for the alcohol to suppress withdrawal symptoms. The client experiences symptoms of withdrawal because of the "rebound phenomenon" when sedation of the central nervous system (CNS) from alcohol begins to decrease. Haloperidol is an antipsychotic and is not indicated for alcohol withdrawal symptoms. Benztropine is used to treat extrapyramidal symptoms associated with antipsychotic therapy. Naloxone is used in opioid overdose to reverse the CNS depression caused by the opioid.
A nurse is providing health teaching to the parents of a 2-year-old child who has been diagnosed with benign febrile seizures. What is the most important information for the nurse to give the parents about this disorder? a) It will result in a developmental delay for the child. b) The seizures will continue throughout the child's life. c) This diagnosis often progresses to one of epilepsy. d) A respiratory or ear infection is usually present.
D. A respiratory or ear infection is usually present. An underlying infectious process is often a stimulating factor that triggers the febrile seizures. Parents should be aware of and instructed in how to treat a febrile child. The other options are not accurate in their presentation of febrile seizures.
A multigravid client who is 10 cm dilated is admitted to the labor and birth unit. In addition to supporting the client, priority nursing care includes: a) Increasing IV fluids. b) Turning on the infant warmer. c) Providing client education regarding care of the newborn. d) Determining the client's preferences for pain control.
B. Turning on the infant warmer. Nursing care for this client includes providing support, preparing for birth, assessing for potential complications, and providing for care of the newborn. Turning on the warmer is the best choice for providing for the care of the newborn. Oxygen and IV fluids may be indicated if variable or late decelerations are noted on the fetal heart monitor, but decelerations are not indicated in the question. It is likely too late for pharmacologic pain relief for a multigravida. Client education regarding care of the newborn is not appropriate at this time.
A 10-year-old with a severe head injury is unconscious and has coarse breath sounds, a temperature of 102.2 degrees F (39 degrees C ), a heart rate of 70, a blood pressure of 130/90, and an intracranial pressure of 36 mm Hg. Which of the following actions should the nurse perform first? a) Suction the child. b) Encourage the parent to talk to the child. c) Administer rectal acetaminophen. d) Administer IV mannitol.
D. Administer IV mannitol. An ICP level greater than 15 mm hg is abnormal. This child's vital signs indicate increased ICP. Mannitol is an osmotic diuretic and will decrease the child's ICP. Suctioning the child will increase the ICP. Encouraging the parent to talk to the child may be comforting but will not decrease the ICP. The priority for this child is decreasing the ICP to avoid further brain injury. The fever is likely from the head injury and will not decrease with acetaminophen. A cooling blanket is the most effective means of reducing temperature in a client with a head injury.
A nurse is about to give a full-term neonate his first bath. How should the nurse proceed? a) Scrub the neonate's skin to remove the vernix caseosa. b) Wash the neonate from feet to head. c) Clean the neonate with medicated soap. d) Bathe the neonate only after his vital signs have stabilized.
D. Bathe the neonate only after his vital signs have stabilized. To guard against heat loss, the nurse should bathe the neonate only after vital signs have stabilized. To avoid altering the skin pH, the nurse should use only mild soap and water. Scrubbing should be avoided because it may cause abrasions, through which microorganisms can enter. The nurse should wash the neonate from head to feet.
A neonate weighing 1870 g with a respiratory rate of 46 breaths/minute, a pulse rate of 175 bpm, and a serum pH of 7.11 has received sodium bicarbonate intravenously. The drug has been effective if the neonate: a) Does not go into metabolic acidosis. b) Does not become edematous. c) Develops respiratory alkalosis. d) Is not dehydrated.
A. Does not go into metabolic acidosis. Metabolic acidosis results from the metabolic changes associated with cold stress. End products of metabolism increase the acidity of the blood, evidenced by a pH of 7.11. Therefore, sodium bicarbonate, which is a buffer base, is often used. Diuretics, not sodium bicarbonate, would be used to combat edema. Intravenous fluids would be used to treat dehydration. Respiratory alkalosis results from excessive carbon dioxide loss, a condition that would be unusual in this neonate. Additionally, because sodium bicarbonate is a base, administering it to client with alkalosis would only further exacerbate the alkalotic condition.
Which of the following should the nurse include in the discharge plan for a client with multiple sclerosis who has an impaired peripheral sensation? Select all that apply. a) Inspect the skin daily for injury or pressure points. b) Wear warm clothing when outside in cold temperatures. c) Avoid kitchen activities because of the risk of injury. d) Avoid hot water bottles and heating pads. e) Carefully test the temperature of bath water.
A. Inspect the skin daily for injury or pressure points. B. Wear warm clothing when outside in cold temperatures. D. Avoid hot water bottles and heating pads. E. Carefully test the temperature of bath water. A client with impaired peripheral sensation does not feel pain as readily as someone whose sensation is unimpaired; therefore, water temperatures should be tested carefully. The client should be advised to avoid using hot water bottles or heating pads and to protect against cold temperatures. Because the client cannot rely on minor pain as an indicator of damaged skin or sore spots, the client should carefully inspect the skin daily to visualize any injuries that he cannot feel. The client should not be instructed to avoid kitchen activities out of fear of injury; independence and self-care are also important. However, the client should meet with an occupational therapist to learn about assistive devices and techniques that can reduce injuries, such as burns and cuts that are common in kitchen activities.
The nurse is caring for a client with an injury to the thalamus. The nurse should plan to: a) Monitor the temperature of the bathwater. b) Give higher doses of pain medication. c) Keep patches on the client's eyes to prevent corneal abrasion. d) Avoid turning the client.
A. Monitor the temperature of the bathwater. The spinal cord connects the brain to the periphery. The thalamus is located in the midbrain and integrates all sensory impulses except olfaction. The afferent impulses are received and then transmitted from the thalamus. Destruction or interruption of the neurosensory pathway results in loss of communication between the two systems. Monitoring the temperature of the bathwater is important because the client cannot feel whether the water is too hot or too cold. Damage to the thalamus does not result in loss of the corneal reflex. Loss of position and vibratory sense usually occurs with degeneration of the posterior column of the spinal cord; therefore, turning every 2 hours is critical to prevent skin breakdown related to increased capillary pressure. The nurse can give only the prescribed dosage of pain medication.
Just after delivery, a nurse measures a neonate's axillary temperature at 94.1°F (34.5°C). What should the nurse do? a) Rewarm the neonate gradually. b) Give the baby a bath. c) Notify the physician when the neonate's temperature is normal. d) Observe the neonate hourly.
A. Rewarm the neonate gradually. A neonate with a temperature of 94.1°F(34.5°C) is experiencing cold stress. To correct cold stress while avoiding hyperthermia and its complications, the nurse should rewarm the neonate gradually, observing closely and checking vital signs every 15 to 30 minutes. Rapid rewarming may cause hyperthermia. Bathing the baby will further cause the baby to lose heat. Hourly observation isn't frequent enough because cold stress increases oxygen, calorie, and fat expenditure, putting the neonate at risk for anabolic metabolism and possibly metabolic acidosis. A neonate with cold stress requires intervention; the nurse should notify the physician of the problem as soon as it's identified.
Before surgery a client states that she is afraid of surgery because her cousin died in surgery when having her tonsils removed. What is the nurse's best response? a) Reassure the client that technology has changed over the last 10 years. b) Ask the client if anyone else in her family has had trouble when they had surgery. c) Explain to the client that it is normal to be afraid. d) Encourage the client to further express her concerns.
B. Ask the client if anyone else in her family has had trouble when they had surgery. The nurse should immediately think of the congenital metabolic tendency for malignant hyperthermia, which occurs in the presence of certain kinds of anesthetics. Whenever a preoperative client states that a family member has had problems with anesthesia or surgery, the nurse should inquire about the nature of the problems and whether other family members have had similar problems. Reassuring the client that technology has changed will do little to affect her fears and misses the opportunity to evaluate the risk for malignant hyperthermia. Encouraging the client to further express her concerns and reassuring her that her feelings are normal are important, but missing a familial tendency of malignant hyperthermia could be fatal.
A neonate born 2 hours ago has just arrived in the nursery. Which nursing measure will prevent the neonate from losing heat by evaporation? a) Keeping him away from drafts b) Drying him thoroughly after a bath c) Putting a cap on his head d) Putting a blanket between him and cold surfaces
B. Drying him thoroughly after a bath Neonates lose heat through evaporation as liquid is converted to a vapor. Drying a neonate after birth and following a bath prevents heat loss by evaporation. Keeping a neonate away from drafts prevents heat loss through convection. Keeping a neonate off a cold surface, such as a scale, prevents the loss of heat through conduction. Placing a cap on the neonate's head preserves heat and prevents heat loss from radiation.
A nurse is assigned to a client with a cardiac disorder. The nurse should question an order to monitor the client's body temperature by which route? a) Axillary b) Tympanic c) Rectal d) Oral
C. Rectal When caring for a client with a cardiac disorder, the nurse should avoid using the rectal route to take temperature. Using this route could stimulate the vagus nerve, possibly leading to vasodilation and bradycardia. The other options are appropriate routes for measuring the temperature of a client with a cardiac disorder.
A primigravid client at 36 weeks' gestation with premature rupture of the membranes is to be discharged home on bed rest with follow-up by the home health nurse. After instruction about care while at home, which of the following client statements indicates effective teaching? a) "It is permissible to douche if the fluid irritates my vaginal area." b) "I can take either a tub bath or a shower when I feel like it." c) "I should limit my fluid intake to less than 1 quart (0.95 L) daily." d) "I should contact the doctor if my temperature is 100.4° F (38°C) or higher."
D. "I should contact the doctor if my temperature is 100.4° F (38°C) or higher." Because of the client's increased risk for infection, successful teaching is indicated when the client states that she will contact the doctor if her temperature is 38° C (100.4° F) or greater. The client should be instructed to monitor her temperature twice daily. The client should refrain from coitus, douching, and tub bathing, which can increase the potential for infection. Showering is permitted because water in the shower doesn't enter the vagina and increase the risk of infection. A fluid intake of at least 2 L daily is recommended to prevent potential urinary tract infection.
