Health Care Concepts 1 PrepU
The nurse is teaching nursing students about the risks that late preterm infants may experience. The nurse feels confident learning has taken place when the students make which statement?
"A late preterm newborn may have more clinical problems compared with full-term newborns."
Which client statement indicates a need for additional teaching about self-care during pregnancy?
"I should sit in a hot tub for 20 minutes to relax after working." The client needs further instruction when she says it is permissible to sit in a hot tub for 20 minutes to relax after working. Hot tubs and saunas should be avoided, particularly in the first trimester, because their use can lead to maternal hyperthermia, which is associated with fetal anomalies such as central nervous system defects. The client should use nonskid pads in the shower or bath to avoid slipping because the client's center of gravity has shifted and she may fall. The client should avoid using soap on the nipples to prevent removal of the natural protective oils. Douching is not recommended for pregnant women because it can destroy the normal flora and increase the client's risk of infection.
The nurse is caring for a child who sustained a spinal cord injury in a motor vehicle accident. The child's body temperature fluctuates markedly, and the parents question why this is occurring. What is the most accurate response for the nurse to give to the parents?
"The child's sympathetic nervous system was damaged in the accident."
When assessing an infant's axillary temperature, it will be:
1°F (0.5°C) lower than an oral temperature.
On what client would it be appropriate for the nurse to perform a rectal temperature?
A child who has suffered a head injury and is comatose Rectal temperatures are not the preferred method of obtaining a child's temperature but are appropriate if the child is unconscious and the nurse cannot do an oral temperature. Clients who have diarrhea, hemorrhoids or are cardiac patients are not appropriate candidates for rectal temperatures. The rectal thermometer can cause arrhythmias in cardiac patients, irritate the rectal mucosa further in patients with diarrhea and in newborns.
The nurse is caring for a client in septic shock. The nurse knows to closely monitor the client. What finding would the nurse observe when the client's condition is in its initial stages?
A rapid, bounding pulse A rapid, bounding pulse is observed in a client in the initial stages of septic shock. In case of hypovolemic shock, the pulse volume becomes weak and thready and circulating volume diminishes in the initial stage. In the later stages when the circulating volume has severely diminished, the pulse becomes slow and imperceptible and pulse rhythm changes from regular to irregular.
Which of the following measures can be used to cool a burn?
Application of cool water
The client has been brought to the emergency department by their caregiver. The caregiver says that she found the client diaphoretic, nauseated, flushed and complaining of a pounding headache when she came on shift. What are these symptoms indicative of?
Autonomic dysreflexia
A nurse is performing a physical examination on a newborn. Which assessment should she include?
Axillary temperature, femoral pulse, head circumference When examining newborns, take axillary or temporal temperatures to prevent rupture of rectal mucosa. Be certain to take femoral pulses in newborns to rule out coarctation of the aorta. Include newborn reflexes, head circumference, and an assessment of gestational age as routine parts of the examination. Taking blood pressure is not necessary because this value is unreliable in newborns.
The nurse is teaching a young couple, who desire to start their family, the various methods for determining fertility. After discovering the woman regulary travels internationally for work, deals with a lot of job anxiety and frequently uses an electric blanket at home, the nurse will discourage the use of which method?
Basal body temperature (BBT) method Explanation: BBT is a method where the body temperature should be check first things in the morning and recorded, immediately after waking and before getting out of bed. It is important for the patient to maintain a normal bed-time routine. Use of the electric blanket can cause a false elevation in the BBT. The calendar method would depend upon her schedule. Cervical mucus and symptothermal methodology would still be options. p105
The nurse walks into a client's room and notes a small fan blowing on the mother as she holds her infant. The nurse should explain this can result in the infant losing body heat based on which mechanism?
Convection
A patient receiving succinylcholine (Anectine) experiences malignant hyperthermia. What drug is used to treat this condition?
Dantrolene (Dantrium)
What medication should the nurse prepare to administer in the event the patient has malignant hyperthermia?
Dantrolene sodium (Dantrium)
A 6-month-old is admitted to the hospital because of a fever. When you obtain a health history, what data would you obtain first?
Details about the fever
A person's core body temperature is highest in the early morning and lowest in the late afternoon.
False
A nurse is asked to teach a woman to take her basal body temperature daily to assess the time of ovulation. She can detect her day of ovulation, following ovulation, because her temperature will:
Increase a degree
The temperature is 102°F (39°C) during a heat wave. The nurse can expect admissions to the emergency room to present with:
Increased temperature
A nurse is caring for a preterm newborn born at 29 weeks' gestation. Which nursing diagnosis would have the highest priority?
Ineffective thermoregulation related to decreased amount of subcutaneous fat
During a procedure, a client's temperature begins to rise rapidly. This is likely the result of which complication?
Malignant Hyperthermia Malignant hyperthermia is an inherited disorder that occurs when body temperature, muscle metabolism, and heat production increase rapidly, progressively, and uncontrollably in response to stress and some anesthetic agents. If the client's temperature begins to rise rapidly, anesthesia is discontinued, and the OR team implements measures to correct physiologic problems, such as fever or dysrhythmias. Hypothermia is a lower than expected body temperature. Signs of infection would not present during the procedure. Increased body temperature would not indicate fluid volume excess.
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
An operating room nurse is assisting the anesthesiologist in the preparation of an intravenous dose of dantrolene. What emergent issue most likely prompted the need to give the patient dantrolene?
Malignant hyperthermia
A 23-month-old child pulls a pan of hot water off the stove and spills it onto her chest and arms. Her mother is right there when it happens. What should the mother do immediately?
Place the child in a bathtub of cool water.
Approximately 15 minutes after giving birth to a viable term neonate, a multiparous client has chills. What should the nurse do next?
Provide the client with a warm blanket.
Which term indicates a potentially serious client condition?
Pyrexia
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?
Rectal
A nurse is caring for an adult with fever. The nurse determines that which site is most ideal for obtaining the client's core body temperature?
Rectum
A 13-year-old has been admitted with a diagnosis of rheumatic fever and is on bed rest. He has a sore throat. His joints are painful and swollen. He has a red rash on his trunk and is experiencing aimless movements of his extremities. Use the chart above to determine what the nurse should do first.
Report the heart rate to the health care provider (HCP).
The nurse is caring for a 12-year-old girl with Crohn disease. A primary assessment the nurse would want to make when caring for her would be to note if:
She has a temperature
A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention?
Shivering Shivering can increase intracranial pressure by increasing vasoconstriction and circulating catecholamines. Shivering also increases oxygen consumption. A capillary refill of 2 seconds, urine output of 100mL/hr, and cool, dry skin are expected findings.
Parents tell the nurse that they have been told to keep their newborn away from windows and be sure to cover the baby with a light blanket. They do not understand why this is necessary. What rationale would the nurse provide for this care?
Since newborns cannot shiver to produce heat, parents need to be sure to keep them covered up and away from sources of heat loss like a window.
A nurse is monitoring a client closely for malignant hyperthermia because the client received which NMJ blocker?
Succinylcholine
For which assessment finding will the nurse intervene first when providing postoperative care to a patient who returned to the nursing unit 2 hours after receiving succinylcholine (Anectine)?
Temperature 40 degrees C (104 degrees F)
The nurse is caring for a patient with hyperthyroidism who suddenly develops symptoms related to thyroid storm. What symptoms does the nurse recognize that are indicative of this emergency?
Temperature of 102ºF
A client is being evaluated for hypothyroidism. During assessment, the nurse should stay alert for:
decreased body temperature and cold intolerance.
A nurse is assessing vital signs for a postpartum client 48 hours after birth. The vital signs are: T 101.2° F; (38.4° C) HR 82 beats/min.; RR 18 breaths/min.; BP 125/78 mm Hg. How will the nurse interpret the vital signs?
infection Temperatures elevated above 100.4° F (38° C) 24 hours after birth are indicative of possible infection.
The nurse is caring for a client with an injury to the thalamus. The nurse should plan to:
monitor the temperature of the bathwater.
A nurse is working in the newborn observational unit and is assigned four newborns. In which newborn will the nurse suspect difficulties with thermal regulation?
newly born preterm infant Newborns use nonshivering thermogenesis for heat production by metabolizing their own brown adipose tissue. The preterm newborn has an inadequate supply of brown fat. The preterm newborn also has decreased muscle tone and thus cannot assume the flexed fetal position, which reduces the amount of skin exposed to a cooler environment. Preterm newborns have large body surface areas compared to their weight. A term infant with RH factor will not be at any greater risk for heat lost and stabilized with age. A 2-day-old infant postmaturity would not be stabilized and would initially be at risk for heat loss. The diabetic infant is stabilized and heat loss is not a great concern. pg 850
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:
rest in an air-conditioned room.
The nurse is preparing to apply a thermistor probe to a newborn to monitor the newborn's temperature. At which location would the nurse apply the probe?
right upper abdominal quadrant
The nurse in the NICU is caring for preterm newborns. Which guidelines are recommended for care of these newborns? Select all that apply.
• Dress the newborn in ways to preserve warmth. • Take the newborn's temperature often. • Supply oxygen for the newborn, if necessary. Explanation: Controlling the temperature of preterm newborns is often difficult; therefore, special care should be taken to keep these babies warm. Nurses should dress them in a stockinette cap, take their temperature often, and supply oxygen, if necessary. To conserve the energy of small newborns, the nurse should handle them as little as possible. Usually, they will not give them a bath immediately. Parents should be encouraged to bond with their infants.
