NU372 Week 3 EAQ Evolve Elsevier: Thermoregulation (Custom Quiz)

When a family member of a client with cardiogenic shock asks the nurse for more information about the condition, how would the nurse describe cardiogenic shock? o An irreversible phenomenon o A failure of the circulatory pump o Usually a fleeting reaction to tissue injury o Generally caused by decreased blood volume

o A failure of the circulatory pump · In cardiogenic shock, ineffective cardiac pumping or contraction is the cause of the poor peripheral circulation. In the early stages, cardiogenic shock is reversible. Cardiogenic shock indicates a severe and usually chronic decrease in cardiac function and is not a fleeting reaction to tissue injury (such as might occur with anaphylactic shock). Cardiogenic shock is caused by poor cardiac function and results in hypervolemia. A decrease in blood volume would cause hypovolemic shock.

Which causative agent is common to both hyperthermia and hypothermia? o Alcohol o Barbiturates o Phenothiazines o Cardiovascular disease

o Alcohol · Alcohol is the causative agent that is common to both hyperthermia and hypothermia. Barbiturates and phenothiazines can cause hypothermia. Cardiovascular disease can cause hyperthermia.

Which finding by the nurse who is caring for a client after major abdominal surgery may indicate impending hypovolemic shock? o Urine output 1000 mL in 8 hours o Oral temperature 101°F (38.3°C) o Client report of feeling very thirsty o Bounding radial and femoral pulses

o Client report of feeling very thirsty · With hypovolemic shock, extravascular fluid depletion leads to client feeling of thirst. With hypovolemia, urine output will decrease due to compensatory mechanisms designed to retain volume. Elevated temperature might occur with septic shock, but temperature may be lower with hypovolemia because of poor perfusion. With hypovolemia, pulses would be weak.

Which assessment finding will the nurse expect when caring for a client who has cardiogenic shock? o Cold, clammy skin o Slow, bounding pulse o Increased blood pressure o Hyperactive bowel sounds

o Cold, clammy skin · In cardiogenic shock, the action of the sympathetic nervous system causes vasoconstriction, which causes the skin to be cold and clammy. The heart rate increases in an attempt to meet the body's oxygen demands and circulate blood to vital organs. Because of poor cardiac contractility, pulse quality is weak. Blood pressure decreases because of poor cardiac output. Hypoperfusion leads to hypoactive or absent bowel sounds.

Which finding will the nurse expect when caring for a client who is in hypovolemic shock? o Slow heart rate o Cool skin temperature o Bounding radial pulses o Increased urine output

o Cool skin temperature · Shunting of blood to vital organs such as the heart and brain occurs in hypovolemic shock, leading to cool skin because of decreased skin perfusion. Tachycardia, not bradycardia (slow heart rate), occurs as a compensatory mechanism in hypovolemic shock. The pulses in hypovolemic shock are weak and thready because of decreased blood pressure. Urine output will decrease because of decreased kidney perfusion in hypovolemic shock.

A client with hypothermia is brought to the emergency department. Which treatment would the nurse anticipate? o Core rewarming with warm fluids o Ambulation to increase metabolism o Frequent oral temperature assessments o Gastric tube feedings to increase fluid volume

o Core rewarming with warm fluids · Core rewarming with heated oxygen and administration of warmed oral or intravenous fluids is the preferred method of treatment. The client will be too weak to ambulate. Oral temperatures are not the most accurate assessment of core temperature because of environmental influences. Warmed oral feedings are advised; gavage feedings are unnecessary.

Which changes that occur with aging increase the risk for hypothermia in older adults? Select all that apply. o Increased metabolic rate o Increased shivering response o Decreased amount of body fat o Diminished energy reserves o Chronic medical conditions

o Decreased amount of body fat o Diminished energy reserves o Chronic medical conditions · Many older adults have decreases in body fat, diminished energy reserves, and chronic medical conditions that increase the risk for hypothermia when exposed to cold. Metabolic rate slows with aging, which increases hypothermia risk. The shivering response to cold decreases with age, and this increases hypothermia risk.

While assessing a neonate's temperature, the nurse observes a drop in the body temperature. Which would be the reason for this temperature drop? o Increased basal metabolic rate o Decreased involuntary shivering o Increased voluntary movements o Decreased nonshivering thermogenesis

o Decreased nonshivering thermogenesis · Neonates are susceptible to heat loss or cold stress. Nonshivering thermogenesis is a natural mechanism of heat production that occurs to minimize heat loss in a neonate. This mechanism's failure may lead to a drop in body temperature. The basal metabolic rate (BMR) accounts for heat production; an increased BMR may raise the body temperature. Shivering is an involuntary movement that produces heat, which may not be seen in neonates. Voluntary movements cause increases in body temperature.

When a client is admitted to the emergency department with disseminated intravascular coagulation caused by sepsis, which prescribed action will the nurse take first? o Apply antiembolism stockings. o Draw blood for culture and sensitivity. o Administer vancomycin 1 gram intravenously. o Transfer the client to the intensive care unit.

o Draw blood for culture and sensitivity. · Treatment of disseminated intravascular coagulation focuses on treatment of the cause of the abnormal coagulation, so rapid initiation of antibiotic therapy is essential. However, blood cultures are drawn before antibiotic administration to ensure that appropriate antibiotics can be prescribed. Antiembolism stockings are needed to help prevent venous thrombosis, but are not the priority action. The client needs to be transferred to the intensive care unit, but the nurse would not wait for the transfer to obtain cultures and administer antibiotics.

Which finding is indicative of hypothermia in a newborn? Select all that apply. o Seizures o Diaphoresis o Flushed skin o Poor feeding o Hypoglycemia

o Hypoglycemia · Hypoglycemia in a newborn can indicate hypothermia or cold stress. Seizures, diaphoresis, flushed skin, and poor feeding are indicative of hyperthermia.

The parent of a preterm infant asks the nurse in the neonatal intensive care unit why the baby is in a bed with a radiant warmer. How would the nurse explain the increased risk for hypothermia in preterm infants? o Have a smaller body surface area than full-term newborns o Lack the subcutaneous fat that usually provides insulation o Perspire excessively, causing a constant loss of body heat o Have a limited ability to produce antibodies against infections

o Lack the subcutaneous fat that usually provides insulation · Much of a full-term infant's birth weight (almost a third) is gained during the last month of gestation, and most of this final spurt is related to an increase in subcutaneous fat, which serves as insulation; the preterm infant did not have enough time to grow in the uterus and has little of this insulating layer. The preterm infant has a relatively larger surface area per body weight than does a term infant. Preterm infants do not shiver or perspire. Depressed antibody production is unrelated to maintenance of body temperature.

Which finding would the nurse expect when assessing a client diagnosed with hypovolemic shock? o Oliguria o Crackles o Dyspnea o Bounding pulse

o Oliguria · Urine output decreases to less than 20 to 30 mL/hr (oliguria) because of decreased renal perfusion secondary to a decreased circulating blood volume. Crackles are associated with pulmonary edema caused by cardiogenic shock, not hypovolemic shock. Dyspnea may be associated with hypervolemia, not hypovolemia, and also with pulmonary edema and respiratory disorders. Bounding pulse will occur with hypervolemia.

A client undergoes a subtotal gastrectomy. After surgery the client begins to hemorrhage. Which clinical findings support the nurse's conclusion that the client is experiencing hypovolemic shock? Select all that apply. o Oliguria o Bradypnea o Diaphoresis o Tachycardia o Hypertension

o Oliguria o Diaphoresis o Tachycardia · Decreased blood volume leads to decreased glomerular filtration; compensatory antidiuretic hormone (ADH) and aldosterone secretion cause sodium and water retention, thereby decreasing urinary output. Diaphoresis and tachycardia occur because of the sympathetic nervous system-mediated response. Respirations become rapid and shallow, not slow, because of the sympathetic nervous system-mediated response. Hypotension, not hypertension, is the response to a decrease in circulating blood volume.

A registered nurse (RN) is instructed to assess the body temperature of a neonate. Which site for placing the thermometer is contraindicated in these clients? o Axilla o Oral cavity o Temporal artery o Tympanic membrane

o Oral cavity · The oral cavity is the preferred site for temperature measurement in adult clients. This site is contraindicated for neonates and unconscious or uncooperative clients. The axilla is a safe site for placing a thermometer in neonates. The temporal artery is indicated for rapid temperature measurement. This site is indicated for premature infants, newborns, and children. The tympanic membrane is indicated in newborns to reduce infant handling and heat loss.

When a client with hypovolemic shock has a hematocrit value of 25%, which fluid therapy will the nurse prepare to infuse? o Lactated Ringer solution o Human serum albumin 5% o Packed red blood cells o High molecular weight dextran

o Packed red blood cells · Blood replacement is needed to increase the oxygen-carrying capacity of the blood; the expected hematocrit for women is 37% to 47% and for men is 42% to 52%. The other three fluids will increase volume, but will not improve the oxygen-carrying capacity of the blood. Lactated Ringer solution does not increase the oxygen-carrying capacity of the blood. Serum albumin helps maintain volume but does not affect the hematocrit level. Although dextran does expand blood volume, it decreases the hematocrit because it does not replace red blood cells.

Which activity places a client at risk for hyperthermia? o Snowmobiling o Skiing in the winter o Hiking Alaskan mountains o Performing strenuous activity in high humidity

o Performing strenuous activity in high humidity · When a client performs strenuous activity in high humidity, it reduces heat loss from the body and results in hyperthermia. Activities such as snowmobiling, skiing, and hiking in cold weather may cause hypothermia because they occur in cold temperatures and may lower the body temperature.

The nurse is caring for a client with severe burns and determines that the client is at risk for hypovolemic shock. Which physiological finding supports the nurse's conclusion? o Decreased rate of glomerular filtration o Excessive blood loss through the burned tissues o Plasma proteins moving out of the intravascular compartment o Sodium retention occurring as a result of the aldosterone mechanism

o Plasma proteins moving out of the intravascular compartment · The shift of plasma proteins into the burned area increases the shift of fluid from the intravascular to the interstitial compartment; the result is decreased blood volume and hypovolemic shock. Decreased glomerular filtration may occur because of hypovolemia; it does not cause hypovolemia. Extracellular fluid, not blood, is lost through burned tissue. Sodium is not retained; it passes to interstitial spaces and surrounding tissue.

Which action would be the nurse's priority of care for a client with hypothermia? o Administering electrolytes o Monitoring body temperature o Increasing the temperature of the room o Removing the client from the cold environment

o Removing the client from the cold environment · Hypothermia is associated with a decrease in core body temperature, which requires interventions that lead to an increase in the client's internal body temperature. The client should be first removed from the cold environment. Electrolytes should be administered once the client's temperature is controlled. Monitoring the client's temperature is performed during ongoing assessments after providing initial treatment. Increasing the room temperature should be done after the client is removed from the cold environment.

The nurse is assessing a client who had a bowel resection 4 hours ago. Which finding would the nurse identify as an early sign of shock? o Respirations of 10 o Urine output of 30 mL/hour o Lethargy o Restlessness

o Restlessness · In the early stage of shock, the client has increased epinephrine secretion. This, in turn, causes the client to become restless, anxious, nervous, and irritable. Decreased respiratory rate is a late sign of shock. A urine output of 30 mL/hour is within normal limits. Lethargy is not a sign of shock.

Which statement reflects understanding of sepsis screening requirements by the nurse? o Blood cultures are required to diagnosis sepsis and begin sepsis protocols. o An oral temperature of 96.4°F (35.8°C) is not an indicator of sepsis. o A primary health care provider's prescription is required to screen for sepsis. o Sepsis mortality is affected greatly by treatments performed in the first 6 hours.

o Sepsis mortality is affected greatly by treatments performed in the first 6 hours. · Studies have shown that if a bundle treatment is not performed in the first 6 hours, the likelihood of survival dramatically decreases. Only in about 30% to 40% of the cases are blood cultures positive in septic clients; this is because in many cases sepsis works faster than the laboratory can produce the result using the current technology. Hypothermia is as strong a sepsis indicator as hyperthermia; however, the health care team members often miss this symptom. The signs and symptoms of sepsis are not specific and may indicate many other diseases as well. If the health care team is not actively looking for sepsis, it will be missed. A sepsis screening is an assessment that the nurse can perform at any time. To perform the screening, the nurse analyzes the vital signs, client history, and laboratory reports; the nurse synthesizes the findings to evaluate if sepsis screening is negative or positive and then notifies the primary health care provider of the findings.

During a physical assessment, a client was diagnosed with increased temperature due to an increased basal metabolic rate (BMR). Which hormonal imbalances would the client have? Select all that apply. o Cortisol o Thyroid o Estrogen o Testosterone o Progesterone

o Thyroid o Testosterone · Body temperature is assessed during physical assessment. An increased basal metabolic rate (BMR) increases the body temperature. Hormonal imbalances may alter the BMR. Testosterone regulates the BMR in males. Thyroid hormone regulates the BMR of the body. Increases in the levels of these hormones may increase the BMR, which may in turn raise body temperature. Cortisol regulates blood glucose levels. Estrogen and progesterone are female hormones that do not regulate the BMR.

While performing cardiac surgery, the cardiologist intentionally induces hypothermia in the client. Which rationale explains this intervention by the cardiologist? o To prevent tissue ischemia o To enhance anesthetic action o To prevent blood loss during surgery o To complete the surgery in a short time

o To prevent tissue ischemia · Sometimes, surgeons intentionally induce hypothermia to decrease the oxygen requirement of the tissues and ultimately prevent tissue ischemia. The alteration of body temperature may not enhance the anesthetic action during surgery. Reduced body temperature is unrelated to blood clotting and may not prevent blood loss during surgery. Induced hypothermia is unrelated to the duration of surgery.

The nurse is caring for a client with a temperature of 104.5°F (40.3°C). The nurse applies a cooling blanket and administers an antipyretic medication. Which is the correct rationale for the nurse's interventions? o To promote equalization of osmotic pressures o To prevent hypoxia associated with diaphoresis o To promote integrity of intracerebral neurons o To reduce brain metabolism and limit hypoxia

o To reduce brain metabolism and limit hypoxia · Cooling blankets and antipyretic medications can induce hypothermia, thus decreasing brain metabolism. This in turn makes the brain less vulnerable by decreasing the need for oxygen. The integrity of intracerebral neurons and osmotic pressure equalization depend on an adequate supply of oxygen, carbon dioxide, and glucose, and may occur as a result of decreased cerebral metabolism and hypoxia. Diaphoresis does not cause hypoxia. Antipyretic medications may cause diaphoresis as vasodilation occurs.

Which nursing intervention would prevent septic shock in the hospitalized client? o Maintain the client in a normothermic state. o Administer blood products to replace fluid losses. o Use aseptic technique during all invasive procedures. o Keep the critically ill client immobilized to reduce metabolic demands.

o Use aseptic technique during all invasive procedures. · Septic shock occurs as a result of an uncontrolled infection, which may be prevented by using correct infection control practices. These include aseptic technique during all invasive procedures. Maintaining the client in a normothermic state, administering blood products, and keeping the critically ill client immobilized are not directly related to the prevention of septic shock.

The nurse assesses for which client symptoms that indicate hyperthermia? Select all that apply. o Vasodilation o Dry and flushed skin o Pale and cyanotic skin o Decreased capillary refill o Decreased urinary output

o Vasodilation o Dry and flushed skin o Decreased urinary output · During hyperthermia, vasodilation occurs that causes the flushed appearance of the skin; as a result, the skin may be warm to the touch. Hyperthermia causes loss of water from the body and results in dry skin and mucous membranes, decreased urinary output, and other signs of dehydration and electrolyte imbalance. Clients with hyperthermia may not have pale and cyanotic skin; instead, they have dry, flushed skin. Clients with hyperthermia may not have decreased capillary refill; instead, they have increased capillary refill.