Lecture Exam 3 Thermoregulation/Hyperthermia/Hypothermia QARs
Which are common causes of fever in children? (Select all that apply.) Pyloric stenosis Chickenpox Cystic fibrosis Upper respiratory infection Otitis media
Rationale Common causes for fevers in children include chickenpox, otitis media, and upper respiratory infections. A fever is not a documented manifestation of pyloric stenosis or cystic fibrosis.
Which type of body temperature changes in response to the environment? Physiologic Surface Metabolic Core
Rationale Surface temperature changes in response to the environment. Core temperature remains constant and stays within a specific range. Metabolic and physiologic are not types of body temperature.
A 56-year-old client with a history of A-fib complains of a low-grade temperature of 99.6°F and a "scratchy throat." The assessment shows a slightly red throat, negative for strep. What is the priority nursing plan for this client? Administer Aspirin 350 mg PO Administer Aleve 250 mg PO Administer Motrin 400 mg PO Administer Tylenol 650 mg PO
Administer Tylenol 650 mg PO Rationale: It is important for the nurse to support the client's environment to maintain thermoregulatory mechanisms. Adequate hydration should be maintained, especially when ambient temperatures are very hot. Dehydration can present with a low-grade fever that will resolve when hydration status is corrected. Tylenol (acetaminophen) can be used for the client's low-grade fever and pain. The other medications can be used for pain, inflammation, and/or fever; however, both the NSAIDS (Motrin, Aleve) and aspirin can cause stomach upset, ulcer formation, and bleeding in clients on anticoagulants, such as warfarin (Coumadin).
A 30-year-old pregnant African-American client in her 2nd trimester has a slight cough and a fever of 100°F. Which medication is contraindicated for this client? Panadol Aspirin Aleve Tylenol
Aleve Rationale: Because NSAIDs can cause bleeding, they should be avoided during all stages of pregnancy; Aspirin is relatively safe in intermittent doses in 1st and 2nd trimesters and should be avoided in the 3rd semester. Acetaminophen (Tylenol and Panadol) is relatively safe in all trimesters.
What occurs when human tissue freezes? (Select all that apply.) Ice crystals form. Intracellular potassium increases. Tissues and cells become edematous. Thinning of the blood occurs. Vascular permeability occurs.
As human tissue freezes, ice crystals form, increasing intracellular sodium (not potassium). Vascular permeability occurs, along with an increased viscosity of blood. This leads to cellular and tissue edema
Which is a location where brown fat is deposited in the newborn? Midsternal region Upper arms Thighs Midscapular region
Brown fat, also known as brown adipose tissue (BAT), is deposited in the midscapular region, around the neck, and in the axillae, with deeper placement around the trachea and esophagus, abdominal aorta, kidneys, and adrenal glands.
What are common side effects for the antipyretic medication ibuprofen? (Select all that apply.) Bleeding Upset stomach Blood coagulation Ulcer formation Ringing in the ears
Common side effects for ibuprofen are bleeding, stomach upset, and ulcer formation. Ibuprofen does not cause blood coagulation. Ringing in the ears is an adverse reaction to acetylsalicylic acid (aspirin).
When is hemodialysis used for the treatment of hypothermia? With damage to the vascular system With damage to the blood With damage to the hypothalamus With damage to renal system
Hemodialysis is typically used when hypothermia occurs with damage to the hypothalamus (as in trauma or stroke). Damage to the renal system and damage to the vascular system or the blood are not primary reasons hemodialysis would be used in the treatment of hypothermia.
The healthcare provider prescribes naproxen (Naprosyn) to treat the fever of Madeline Margolis, a 35-year-old client with an infected foot wound. What should the nurse instruct Madeline about taking this medication? Take on an empty stomach first thing in the morning. Take 2 hours after each meal. Take 1 hour before checking temperature at home. Take with food or a full glass of water.
Naproxen (Naprosyn) should be taken with food or a full glass of water to decrease gastric irritation. Taking 2 hours after meals could cause gastric irritation. Taking on an empty stomach could lead to gastric irritation. There is no reason to take the medication 1 hour before checking the temperature.
The daughter of 86-year-old Imelda Nichols is concerned because the client is always complaining about being cold. What should the nurse explain to Imelda's daughter about temperature regulation? "There is less subcutaneous fat and the blood vessels are closer to the skin in an older adult." "Extremes in environmental temperature are well tolerated." "Older adults are homeothermic. The body wants to stabilize the core body temperature within a narrow range." "Older adults are sensitive to extremes in environment temperature because of less efficient temperature regulation."
Older individuals can be at risk for hypothermia because of less efficient thermoregulation. This causes older individuals to be sensitive to extremes in environmental temperatures. Children tolerate extremes in environmental temperature. Newborns have less subcutaneous fat and their blood vessels are closer to the skin. Newborns are homeothermic, which means that the body stabilizes the core body temperature within a narrow range
The nurse caring for a client with hypothermia understands that compensatory mechanisms that are activated during this condition decrease oxygen demands on the body. Which clinical manifestations resulting from this compensatory mechanism will the nurse recognize? (Select all that apply.) Decreased heart rate Increased GI motility Increased heart rate Increased respiratory rate Decreased respiratory rate
Rationale A decrease in the metabolic rate decreases oxygen demands on the body during hypothermia. This compensatory mechanism causes a decrease in both the respiratory rate and the heart rate. GI motility is not increased in hypothermia.
Four-year-old Isaac Greenbaum is brought to the emergency department by his parents after experiencing a seizure. His mother explains that Isaac has been having fevers and this morning she found him seizing in the bed. Mrs. Greenbaum is upset and wants to know if this means Isaac is an epileptic. What should the nurse say to Mrs. Greenbaum? "No but he will have more seizures when he gets a high fever." "Yes because more than one-third of children who have one seizure from a fever will have another one." "Yes because having any seizure means the individual has a seizure disorder." "No and he might not have another because the chance of these goes down after age 5."
Rationale A fever can lead to the development of a febrile seizure or a generalized seizure that occurs in children as a result of a rapid temperature increase. This temperature increase is associated with an acute illness and seen in children from age 6 months to 5 years. More than one-third of all children who have a febrile seizure will have another one; however, if the child is older when the first seizure occurs, the likelihood that another seizure will occur is less. Having a febrile seizure does not mean that the individual has epilepsy.
Thelma Jackson, a 75-year-old client recovering from viral pneumonia, phones the clinic because she is sweating and has a temperature of 101.5degrees°F. What should the nurse suggest Thelma do until she can be seen by the healthcare provider? Alternate doses of acetaminophen with ibuprofen Take acetaminophen every hour Increase fluids Restrict fluids
Rationale A fever causes an increase in insensible water loss from sweating. Dehydration is a particular concern in older adults and treatment includes increasing oral fluids. Restricting fluids will not replace fluid lost through sweating. Hourly doses of acetaminophen could lead to an overdose. There is research supporting that alternating doses of acetaminophen with ibuprofen has no effect in children. This approach has not been studied in the older client and should not be recommended.
While reviewing the intake and output record for Lorenzo Gonzalez, a 70-year-old client with a fever, the nurse notes that Lorenzo ingested 40 ounces of fluid during the previous 24 hours. What should the nurse prepare to do to assist Lorenzo to achieve fluid balance? Begin intravenous fluids Administer acetaminophen Provide a tepid sponge bath Apply a cooling blanket
Rationale Actions to ensure fluid balance in a client experiencing hyperthermia include encouraging an oral fluid intake of at least 2 liters per day. If oral fluids are insufficient, intravenous fluids should be provided. Since the client's oral fluid intake was less than 2 liters (40 ounces = 1200 mL) the nurse should prepare to begin intravenous fluids for the client. A cooling blanket, acetaminophen, and a tepid sponge bath are not interventions to ensure a fluid balance in the client experiencing hyperthermia.
Through diagnostic testing, it is determined that a client experiencing a fever has a systemic infection. Which action should the nurse take to limit the spread of this infection? Monitor electrolyte status. Evaluate fluid balance. Perform effective hand hygiene. Provide antipyretics as prescribed.
Rationale Actions to prevent the spread of infection include performing effective hand hygiene. Evaluating fluid balance and monitoring electrolyte status would be applicable if the fever were impacting the client's fluid and electrolyte balance. Providing antipyretics as prescribed would ensure for the client's comfort.
A client with a fever is complaining of feeling hot and miserable. What should the nurse do to help this client achieve comfort? (Select all that apply.) Remove unnecessary clothing Turn on the circulating fan in the room Administer pain medications as prescribed Change damp bed linens Measure temperature every 2 hours
Rationale Actions to promote comfort in the client with a fever include changing damp bed linens to keep the client's skin dry, removing unnecessary clothing to reduce the feeling of heat, and turning on the circulating fan in the room to help dissipate the heat coming from the patient's skin. Measuring temperature every 2 hours would be actions reduce the client's body temperature and administering pain medications will not promote comfort due to the fever.
A nurse is caring for a client with frostbite to the toes. After rewarming, which intervention will the nurse implement? Elevate the client's legs on pillows Rub the client's legs with lotion Dangle the client's legs off the side of the bed Place compression stockings on the client's legs
Rationale After rewarming, the nurse will elevate the affected extremities to increase blood flow, not place extremities in the dependent position (off the side of the bed). The nurse will not compress or rub the affected extremities, as this can further damage tissues.
A nurse is caring for a 17-year-old client with hypothermia and frostbite who spent the night outside in the elements after passing out from binge- drinking. How does ingestion of alcohol increase the risk of hypothermia? Alcohol causes peripheral vasoconstriction, causing decreased blood flow to the extremities. Alcohol increases the viscosity of the blood, increasing the risk of ice crystals. Alcohol causes peripheral vasodilation, causing a faster drop in body temperature. Alcohol increases the intracellular sodium content, lowering the freezing point of the tissues.
Rationale Alcohol causes peripheral vasodilation, causing a faster drop in body temperature. The other answer choices are incorrect.
After taking a walk, an older adult client complains about feeling hot. How should the nurse respond to the client? "Walking uses the muscles, which produce heat." "The walk might have been too much for you to do at this time." "Heat from the environment is making you feel hot." "I'll check your temperature to make sure you aren't coming down with a fever."
Rationale All muscle activity produces heat and increases the metabolic rate. This is why the client feels hot after walking down the hall. The client is not feeling hot because of the environment. Feeling hot after a walk does not mean that the exercise was too much for the client to do at this time. The client feeling hot does not mean that the client is coming down with a fever.
A client recovering from a foot wound is resting comfortably in bed. During the last vital signs assessment, the client's temperature was 38°C. What action should the nurse provide to this client? Ice pack to the groin Cooling blanket Nothing Tepid sponge bath
Rationale A low-grade fever which is under 38.3°C or 101°F in an adult may not be treated unless the client is experiencing discomfort. Since the client is resting comfortably in bed and has a temperature of 38°C, nothing should be done. A cooling blanket, tepid sponge bath, and ice pack to the groin would be indicated if the client's temperature was higher than low grade.
Which are characteristics of a toxic appearance in a child with a fever? (Select all that apply.) Capillary refill 6 seconds Lethargy Irritability Respiratory rate 8 per minute Blue-tinged lips
Rationale Characteristics of a toxic appearance in children include lethargy, poor perfusion, hypoventilation, and cyanosis. Lethargy, blue-tinged lips, capillary refill of 6 seconds, and a respiratory rate of 8 per minute are characteristics consistent with a toxic appearance in a child. Irritability is not a characteristic of a toxic appearance in a child.
Which are clinical manifestations of a fever? (Select all that apply.) Tachycardia Malaise Tachypnea Fatigue Hypotension
Rationale Clinical manifestations of a fever include fatigue, malaise, tachypnea, and tachycardia. Hypotension is not a clinical manifestation of a fever.
The family of a client with a fever brings a basket of fresh fruit to the client. Which cultural treatment does the nurse suspect the family and client are practicing? Fresh fruit cools a fever Fresh food kills germs Fresh fruit reduces mucous production Fresh fruit increases fluid intake
Rationale Cultural treatments for a fever differ. Some cultures follow the hot and cold theory of diseases as a guide for treating fevers. The terms "hot" and "cold" refer to categories. A fever is a "hot" condition, which is then treated by giving "cold" foods. Cold foods include fresh fruit. The nurse has no information to support the cultural belief that fresh fruit kills germs, increases fluid intake, or reduces mucous production.
A nurse is performing a nursing assessment on an adult client with hypothermia. Which assessments will the nurse anticipate during the health history portion of the nursing assessment? (Select all that apply.) Drug or alcohol use Delayed capillary refill History of exposure to environmental elements History of financial difficulties Blood pressure
Rationale During the health history portion of the nursing assessment, the nurse will assess the client's history of exposure to environmental elements or any financial difficulties, which may prevent the client from adequately heating his home. The nurse would also anticipate a drug and alcohol history as these can place the client at a greater risk for hypothermia. The client's blood pressure and capillary refill are assessed during the physical exam portion of the nursing assessment.
The nurse determines a client with an elevated body temperature is in the plateau phase of the fever. Which nursing assessment finding did the nurse use to come to this conclusion? Client is neither hot nor cold Client is sweating Client is shivering Client asks for another blanket
Rationale During the plateau phase of a fever, a new temperature has been met in the body and the individual feels neither hot nor cold. During the flush phase, the cause of the fever is removed or treated and the hypothalamic thermostat is suddenly reduced to a lower level. The body responds by excessive sweating. During the chill phase, the body performs actions to raise the temperature including shivering and feeling cold.
A school-age child is hospitalized for a fever of unknown origin. The nurse observes the mother stroking the child's arms and legs with a cool, damp washcloth to help bring the fever under control. Which method of heat transfer is the mother using for the fever? Conduction Metabolism Radiation Evaporation
Rationale Heat can be transferred between places or objects. Evaporation is the conversion of water to vapor, which is what occurs when the mother applies cool water to the child's limbs. Radiation is the release of heat through no physical contact. Conduction is the release of heat through physical contact. Metabolism is not a method of heat transfer.
The nurse is caring for a client recovering from abdominal surgery. Which intervention is most appropriate when monitoring a client for infection? Measure temperature every 4 hours Encourage leg exercises while in bed Assist out of bed to a chair Turn and reposition every 2 hours
Rationale In order to monitor a client for infection, the best intervention is assessing temperature at regular intervals. An increased temperature is an indicator of infection. While the other interventions are appropriate for this client, they do not allow the nurse to monitor for infection.
The nurse is caring for a newly admitted client with a body temperature of 103°F. What actions can the nurse take to help reduce the fever until the healthcare provider completes writing admission prescriptions? (Select all that apply.) Provide the client with cold water to drink Administer an average dose of acetaminophen Turn on the circulating fan in the client's room Apply a cool cloth to the back of the neck Remove unnecessary clothing
Rationale Independent nursing interventions for the client with a fever include removing unnecessary clothing, applying a cool cloth to the back of the neck, providing cold oral fluids, and turning on the circulating fan in the client's room. A healthcare provider's order is needed before administering medications to the client.
After a health interview, the nurse incorporates interventions to reduce the risk for developing a fever into a client's plan of care. What assessment findings did the nurse use to plan these interventions? (Select all that apply.) Hip replacement at age 75 Takes insulin for type 2 diabetes mellitus Age 86 Total knee replacement at age 70 Takes steroids for a skin condition
Rationale Individuals at risk for hyperthermia are those who are at risk for health problems that cause fevers. This includes clients with reduced immune responses and the very old. Age 86 indicates the client is very old. Taking steroids for a skin condition will affect the client's immune responses. Having had hip and knee replacements and taking insulin would not increase this client's risk for developing a fever.
During a visit to the home of a new mother, the nurse is concerned that the newborn is cold. What did the nurse observe to cause this concern? Child wearing a hat before being taken outside for a walk in the stroller Mother covering the child with a towel after providing a morning bath Child lying in a bassinette in a diaper and t-shirt in an air conditioned room Mother rinsing hands with warm water before picking the child up from the crib
Rationale Infants are influenced by environmental temperature. If the baby is lying in an air-conditioned room in a t-shirt and diaper, the child's temperature will fall. Covering the baby with a towel after a bath will keep the baby warm. Wearing a hat will keep the baby warm. Warming hands before picking up the baby will not cause the child to become cold.
What can be done to prevent hyperthermia in toddlers attending day care? (Select all that apply.) Provide refrigerated fluids Reduce the length of scheduled nap times Providing areas of shade when playing outdoors Reduce play time outdoors during hot weather Increase the amount of fresh fruit provided
Rationale Interventions to prevent the onset of a febrile seizure include providing refrigerated fluids, reducing play periods outdoors during hot weather, and protecting children playing outdoors with areas of shade. Reducing the length of nap time and increasing the amount of fresh fruit will not prevent the development of febrile seizures in toddlers.
Which categories should be included when planning care for a client with hyperthermia? (Select all that apply.) Pain control Oral mucous membrane status Temperature regulation Fluid balance Skin integrity
Rationale Problem categories to include in the plan of care for a client with hyperthermia include fluid balance, skin integrity, temperature regulation, and oral mucous membrane status. Pain control is not necessarily a problem when planning care for a client with hyperthermia.
Why does a fever cause tachycardia? Increases metabolic rate Increases oxygen demand Increases insensible fluid loss Increases blood flow to the skin
Rationale Tachycardia is the body's way to correct the temperature elevation by increasing the metabolic rate. This causes the pulse rate to increase. An increase in oxygen demand causes tachypnea. Increased insensible fluid loss increases the fluid requirement in a fever. Increased blood flow to the skin causes the skin to feel warm.
A client with a fever of unknown origin is admitted for dehydration. What should the nurse use to help determine the cause of this client's fever? (Select all that apply.) Client age History of substance use Health history Amount of alcohol ingested daily Employment status
Rationale The amount of collaborative care for a client with hyperthermia will depend upon the underlying reason for the fever. This includes studying the client's age and health history. Employment status, history of substance use, and amount of alcohol ingested are areas within the client's lifestyle and do not necessarily impact the client's health history.
The mother of a preschool-age child with a fever is concerned. The child's temperature dropped to normal after receiving a dose of acetaminophen but is again above normal 4 hours later. What should the nurse instruct the mother to do? Give the child a cold bath Give a dose of ibuprofen Take the child to the nearest emergency department Provide another dose of acetaminophen
Rationale The child's temperature may rise again 4 hours after receiving acetaminophen. The mother should check the temperature and give another dose of acetaminophen. Alternating acetaminophen with ibuprofen when treating fevers in children is not recommended. A cold bath could cause chilling in the child. The child does not need to be seen in the emergency department.
The nurse is planning care for a client with hypothermia. Which independent nursing intervention is appropriate? Administer warm oral fluids Obtain the blood glucose level Administer warm IV fluids Order a social worker referral
Rationale The nurse should administer warm oral fluids to the client. The nurse cannot order a social worker referral but can suggest it to the ordering health care provider. Obtaining the blood glucose level and administering warm IV fluids are dependent, not independent nursing interventions.
A nurse is caring for a very-low-birth-weight (VLBW) newborn with hypothermia. Which nursing intervention is most appropriate to implement especially related to the prevention of heat loss? Place undressed in radiant warmer. Monitor for dysrhythmia. Monitor urine output. Place in polyethylene wrapping.
Rationale The nurse should place the newborn in polyethylene wrapping to prevent further heat loss, not place the newborn undressed under a radiant warmer. While it is appropriate for the nurse to monitor for dysrhythmia and urine output, these interventions do not specifically relate to the prevention of heat loss in the child.
A nurse is caring for a client who has hypothermia and frostbite after getting lost in the woods during a family camping trip. Which clinical therapy will the nurse utilize in response to the client's compensatory vasoconstriction? Prepare for amputation as necessary. Protect blisters from tearing. Place areas of frostbite in basin of standing warm water. Rub areas of frostbite.
Rationale The nurse should prepare the client for amputation as necessary. The nurse should not rub or massage areas of frostbite, which can cause further vascular and tissue damage. The nurse should debride any blisters and place areas of frostbite in circulating warm water, not standing warm water.
A nurse is caring for an older adult with hypothermia. The nurse suspects that the client is unable to maintain an adequate temperature at the client's home due to financial problems. Which intervention is most appropriate for this client? Contact the client's utility company. Suggest a representative from financial services see the client. Contact adult protective services. Suggest a medical social worker see the client.
Rationale The nurse should suggest a medical social worker see the client in order to assess the client's ability to maintain a safe environment at home. A representative from the hospital's financial services usually deals with hospital finances, not the client's finances at home. Contacting adult protective services or the utility company prior to social worker assessment is inappropriate.
A nurse is caring for an older adult with hypothermia. The nurse understands that older adults are at greater risk for developing hypothermia than younger adults. Which is true regarding older adults and the risk of hypothermia? The normal aging process decreases metabolism. The normal aging process decreases ability to shiver. The normal aging process decreases pain tolerance. The normal aging process decreases safety awareness.
Rationale The older adult is at greater risk for developing hypothermia due to the normal aging process of decreased metabolism. Aging does not decrease pain tolerance or the body's ability to shiver. While many older adults have alterations of safety awareness, this is not necessarily a result of the normal aging process.
The nurse is evaluating teaching provided to the parents of a toddler about care of the child during a fever. Which statement made by the father indicates that teaching has been effective? "We should call the doctor immediately if our child has a fever and purple spots develop on the skin." "We should call the doctor immediately if our child has a fever that lasts 16 hours." "We should call the doctor within 24 hours if our child has a fever and is drooling. " "We should call the doctor within 24 hours if our child has a fever and difficulty breathing."
Rationale The parents should be instructed to call the doctor immediately if the child has a fever and develops purple skin spots. The doctor should be called immediately if the child with a fever is drooling or has difficulty breathing. The doctor should be contacted within 24 hours if a child has a fever that lasts longer than 24 hours.
The nurse is instructing a client recovering from a fever on ways to prevent fluid imbalance should a fever recur. What should the nurse teach the client to maintain fluid balance? Ingest at least 1 liter of hot fluids each day Wear sufficient clothing to encourage sweating Take a hot shower after spending time outdoors Drink at least 2 liters of cool fluid each day
Rationale To maintain fluid balance during a fever, the nurse should instruct the client to drink at least 2 liters of cool fluid each day. Ingesting warm fluids will not help maintain fluid balance during a fever. Wearing clothing to cause sweating could increase insensible fluid loss and contribute to a fluid imbalance during a fever. Taking a hot shower after spending time outdoors could cause the client's temperature to rise and further increase insensible water loss.
A nurse is caring for a client with hypothermia who is confused and disoriented. What is the primary reason for the client's disorientation? Decreased levels of serum carbon dioxide Vasodilation of cerebral blood vessels Vasoconstriction of cerebral blood vessels Effects secondary to respiratory alkalosis
Rationale Vasoconstriction of cerebral blood vessels decreases cerebral blood flow, causing confusion and disorientation. Serum carbon dioxide levels would typically increase, not decrease, leading to respiratory acidosis due to a decrease in respiratory rate.
A nurse is caring for a client with severe frostbite to the fingers. The nurse understands that excessive handling of the client's extremities can result in cardiac alterations. Which is the most common cardiac dysrhythmia that occurs with excessive handling of the client's frostbitten extremities? Ventricular fibrillation Premature ventricular contractions (PVCs) Atrial tachycardia Premature atrial contractions (PACs)
Rationale Ventricular fibrillation is a potentially lethal cardiac dysrhythmia, which is most commonly found with excessive handling of the client's frostbitten extremities. The other dysrhythmias may occur; however, they are not the most commonly found dysrhythmia.
A school-age child is brought to the emergency department after falling into a cold lake. Which observations indicate to the nurse that the child's body is attempting to regulate temperature? (Select all that apply.) The child's hands and feet are ice cold. The child is shivering. The child is sleepy. The child is asking for something to drink. The child's respiratory rate is 10 breaths per minute.
Rationale When the skin is chilled, the body attempts to regulate temperature by vasoconstriction of blood vessels. This could be why the child's hands and feet are ice cold. The body also shivers to increase heat production. The body does not regulate temperature through sleep, thirst, or by reducing the respiratory rate.
Which should be done to treat a child with a fever? (Select all that apply.) Monitor response to antipyretic medication Check temperature every 2 hours with a thermometer Sponge with rubbing alcohol Keep fully dressed Provide alternating doses of ibuprofen and acetaminophen
Rationale When treating a child with a fever, the child's response to antipyretic medication should be monitored and temperature should be checked every 2 hours. The child should be wearing a light layer of clothing. Alcohol should not be used to sponge the child. Alternating doses of ibuprofen and acetaminophen should not be provided.
A nurse is caring for a hypothermic client who has damage to the hypothalamus after suffering a massive stroke two days ago. Which therapies will the nurse anticipate that are unique to hypothermia related to hypothalamic damage? (Select all that apply.) Peritoneal dialysis Colonic irrigation Whirlpool therapy Hemodialysis Rewarming therapy
Rationale Hemodialysis, colonic irrigation, and peritoneal dialysis are unique therapies typically reserved for clients with hypothermia related to hypothalamic damage. Rewarming techniques and whirlpool therapy are used in all clients with hypothermia or frostbite.
A client in the third trimester of pregnancy has a fever caused by an infected hand wound. Which medication should the nurse expect to be prescribed for this client to treat the fever? Acetaminophen Acetylsalicylic acid Naproxen Ibuprofen
Rationale: Acetaminophen is relatively safe in all trimesters of pregnancy. Ibuprofen and Naproxen should be avoided during pregnancy. Acetylsalicylic acid should be avoided during the third trimester of pregnancy.
The nurse is preparing information about safety during hot weather for a community health fair. What information should the nurse include for the community members? (Select all that apply.) Spend time outdoors during the hours of 10 amdash-2 pm. Limit the intake of alcohol to the end of the day. Drink fluids throughout the day. Wear a hat. Drink extra fluids when exercising or working out of doors.
Rationale: Actions to ensure thermoregulation during hot weather include wearing a hat, drinking an adequate amount of fluids, and drinking extra fluids when exercising. Alcohol is not recommended for use during hot weather. The sun is hottest between the hours of 10 amdash-2 pm. Being outside during those hours may promote heat related illnesses.
During a home visit, the nurse determines the outcome of care provided to a client who developed a postoperative fever. Which outcome indicates that care has been successful? Client's body temperature is 98.4degrees° F without the use of antipyretics Client heart rate is 100 beats per minute and respirations are 28 Client appears flushed and skin warm to the touch Client's temperature spikes occur only during the night
Rationale: Evidence that interventions to reduce a fever were effective would be the client having a normal body temperature without the use of antipyretics. Flushed and warm skin indicates the client is still experiencing a fever. Temperature spikes indicate that the fever is still present. A heart rate of 100 and respiratory rate of 28 indicate the client's metabolic rate is still being affected by the fever.
The nurse is teaching a client who will undergo heart surgery about what the client can expect when waking from anesthesia. The nurse explains that the client will experience cold, which is induced during surgery to: Make the surgery go faster. Decrease bleeding during surgery. Reduce the demand for tissue oxygenation. Keep the doctors cool under the lights.
Rationale: Heat increases the metabolic rate and increases the need for oxygen. During cardiac surgery, the temperature is intentionally lowered so the client's metabolic rate is low, thus decreasing the demand for oxygen. Cold does not make the surgery go faster or decrease bleeding. A colder surgery suite does help cool the doctors under the hot lights, but that is not the rationale for the cool temperature during cardiac surgery.
The nurse is caring for a postoperative client whose temperature is 96.1°F. Hypothermia in the postoperative period: Increases cardiac ischemia. Increases client comfort and analgesia. Reduces the risk for wound infection. Requires interventions to prevent and relieve.
Rationale: Hypothermia can result from the operating room environment since anesthesia blocks sympathetic nervous system stimulation, preventing the client from shivering. Thus, it is necessary to assess and intervene to help increase body temperature. Hypothermia does not increase cardiac ischemia or reduce the risk for wound infection or increase comfort.
The nurse is assessing a 65-year-old client who complains chills and fever after being locked outside his house for 20 minutes in 30° weather. What are the nurse's priority interventions for this client? Administer tepid sponge bath, monitor vital signs, and provide dry clothing. Use a heat lamp, reduce clothing, and keep limbs close to body. Monitor vital signs, assess skin color, and use a hyperthermia blanket. Assess skin and temperature, cover head with cap, and use a hypothermia blanket.
Rationale: Hypothermia is a decrease in body temperature as a result of more heat lost than produced. Therapies include: monitoring vital signs, assessing skin color and temperature, applying warm blankets (hyperthermia blanket) or warm clothing, providing a warm environment, keeping limbs close to body, covering head with cap or turban, administering warmed oral or IV fluids, and using heat lamps, hot water bottles, or heating pad.
A 4-year-old child in the emergency department has a body temperature of 103°F. Which body systems should the nurse focus on to help determine the cause of this fever? (Select all that apply.) Gastrointestinal Respiratory Neurological Musculoskeletal Urinary
Rationale: Infections are the most common reason for a fever in this age range. The causes for fever include colds, gastroenteritis, ear infections, croup, bronchiolitis, and urinary tract infections. The nurse should focus on the child's respiratory, urinary, and gastrointestinal systems. The neurological and musculoskeletal systems are not common systems for infections in children.
A 27-year-old client complains of intermittent low-grade temperatures over a 1 month time period. The nurse performs which priority test to determine the cause of fever? An hCG blood or urine test A serum hormone study A complete blood count with differential A fasting hCG blood test
Rationale: Laboratory tests for women related to the genitoreproductive system include hCG (human chorionic gonadotropin), pregnancy tests (urine or blood), and Papanicolaou test (Pap test). Since the Pap test involves a pelvic examination, more teaching about the procedure and the test is required. The pregnancy tests and Pap test do not require the woman to be fasting.
A 22-year-old mother is instructed by the nurse the accurate use and reading of a thermometer for her newborn. The mother calls the nurse after she gets an axillary reading of 100°F and states the 20-day-old is "lethargic." What is the appropriate response by the nurse? "Give the infant a bottle of cool water." "Bring your infant to the doctor's office immediately." "Give your infant a dose of ibuprofen elixer." "Call 911 immediately."
Rationale: Newborns up to 28 days old with fever should be admitted to the hospital (Graneto, 2013). Initiating an IV access is important, and antipyretics should be given as soon as possible after admission to the ED.
The nurse is admitting a client who is experiencing a panic attack. The nurse would expect which finding during assessment? Elevated temperature Decreased blood pressure Dry skin Client calm and relaxed
Rationale: Stimulation of the sympathetic nervous system during a panic attack causes the release of epinephrine and norepinepherine, which increases blood temperature and blood pressure. The client in a panic attack is restless and pacing. Since the client is likely to have an elevated temperature, the nurse would find moist, sweaty skin.
The nurse is planning care for a client with pyrexia from streptococcus and selects hyperthermia as a nursing diagnosis. Which intervention will the nurse implement as priorities of care for this client? (Select all that apply.) Provide a warm environment. Reduce client's physical activity. Provide frequent linen changes. Supply warm fluids. Monitor white blood cell count.
Rationale: Strep is a bacteria that causes fever, and the nurse would monitor the white blood cell count for continued elevation. The client with a fever will sweat, and changing linens is important to maintain skin integrity. Physical activity generates heat production, so the client is kept quiet. A warm environment will increase the client's temperature as will ingesting warm fluids.
The nurse is teaching a class for clients aged 32-47 who jog in the park during warm weather. The nurse concludes that further teaching is necessary with which client statement? "I can keep jogging if I am not sweating." "I should rest and drink water if I get dizzy." "I should stop jogging if I become flushed." "I should drink plenty of water while jogging in the heat."
Rationale: The client who has stopped sweating while jogging in the heat is at risk for developing heat stroke; by not sweating, the body is attempting to conserve fluid. Drinking while jogging helps hydration and keeps the body temperature lower. Flushing is a sign of possible heat stroke. Dizziness is a sign of heat exhaustion, so the client should stop jogging.
A 26-year-old mother brings her 5-year-old child to the clinic. The child has a temperature of 104.5°F, but her other vital signs are stable. The child has no complaints and is coloring as the nurse completes an assessment. What is the best response made by the nurse? "As long as your child is playing and vital signs are within normal limits, she is tolerating the high temperature; we will keep an eye on her." "Place your child in a tub of alcohol when you get home in order to cool her down." "A seizure is imminent; please take your child to the hospital immediately." "We will feed her ice-chips until she cools down."
Rationale: The hypothalamus is the center that controls the core temperature, specifically the preoptic area of the hypothalamus. As with many of the processes in the human body, temperature is age related. The nurse should understand the differences that can be present when dealing with clients. Until they reach puberty, children's temperatures continue to be more variable than those of adults. Children often have extreme high temperatures and tolerate them well. A healthy child can handle a temperature as high as 106°F without difficulty.
The nurse is taking care of a 26-year-old client with a right leg stabbing injury. The client states, "I feel as if I have a fever." The nurse notes that the injury site is red and swollen. The client's temperature is 101°F. What is the nurse's priority implementation? Administer IV normal saline at 50 ml/hr. Call the physician for orders. Administer Tylenol 650mg PO now. Administer prescribed antibiotics.
Rationale: The increased blood flow (hyperemia) causes redness and heat at the injury site (localized thermic response). An increase in body temperature helps the body fight the infection. Also, a fever alerts the immune system to increase production of white blood cells and antibodies. The focus is infection prevention and health maintenance and promotion.
A 65-year-old client with a history of cardiomyopathy is seen in the clinic. The client, who complains of "feeling hot," is diaphoretic, clammy, and nauseous. What is the best assessment procedure to use in order to determine the client's temperature? Oral Tympanic membrane Axillary Rectum
Rationale: The most common sites for measuring body temperature are the mouth, rectum, armpit, tympanic membrane, and temporal artery, which are accessed through the skin of the forehead. The best one for this client is axillary; while the thermometer must be left in place a long time to obtain an accurate measurement, it is safe and noninvasive. While the tympanic membrane is readily accessible, fast, and accurately reflects the body's core temperature, it can be uncomfortable and involves risk of injury to the tympanic membrane if inserted too far. The rectal route is a reliable measurement but is inconvenient and unpleasant for clients and is contraindicated in clients with cardiac problems. This client is nauseous, so the thermometer can break if inadvertently bitten.
The nurse is caring for a 70-year-old client admitted for treatment of gout who takes diazepam (Valium) for an anxiety disorder. The nurse would select which appropriate nursing diagnosis for the client? Defensive Coping Risk for Imbalanced Body Temperature Death Anxiety Activity Intolerance
Rationale: The older client has a slower metabolic rate and decreased activity, which puts the client at risk for hypothermia. The older client who is on a sedative is at a much higher risk for hypothermia. There is no evidence here that this client is experiencing death anxiety, activity intolerance, or defensive coping.
The nurse is evaluating teaching provided to the parents of 2-year-old twins regarding temperature measurement devices in the home. Which observations indicate that teaching has been effective? (Select all that apply.) There is no evidence of temperature measuring device in the home. Separate mercury glass thermometers are available for each child. Pad and pencil are placed next to the temperature-measuring device. Mercury glass thermometers are removed from the home. An electronic thermometer with disposable covers is in the children's bedroom.
Rationale: The parents should have been instructed to remove mercury glass thermometers from the home. Paper and a pencil should be near the thermometer so that the measurement can be documented after taking. An electronic thermometer with disposable covers is an appropriate and safe measuring device to use with children. There should not be mercury glass thermometers in the house, so their presence indicates that teaching was not effective. The absence of a temperature-measuring device in the home indicates that teaching has not been effective.
The nurse is preparing to use the tympanic membrane to measure the temperature of a 4-year-old child. Which approach should the nurse take when completing this measurement? Pull the earlobe back and down. Pull the earlobe back and up. Pull the pinna back and up. Pull the pinna back and down.
Rationale: The pinna is pulled straight back and upward when taking temperature in children over 3 years of age. To measure temperature using the tympanic membrane in an infant, the pinna is pulled straight back and slightly downward. The earlobe is not manipulated to measure temperature using the tympanic membrane.
The nurse needs to monitor the temperature of a client with a bleeding disorder. Which noninvasive methods should the nurse use to measure this client's temperature? (Select all that apply.) Temporal artery Axillary Oral Rectal Tympanic membrane
Rationale: The two methods of measuring temperature that are safe and noninvasive are the axillary method and temporal artery. The client could bite down during the oral approach and damage sensitive oral mucosa. The rectal method is invasive and could damage sensitive tissue. The tympanic membrane could be punctured if this approach is used.
The nurse is preparing to assess an 18-month-old client's temperature. Which reason should the nurse avoid using the tympanic membrane for this temperature measurement? Presence of ear drainage tubes Experiencing projectile vomiting Demonstrating irritability and crying Presence of a total body rash
Rationale: The tympanic route should be avoided in a child with an active ear infection or tympanic membrane drainage tubes. A body rash, projectile vomiting, or crying and irritability are not contraindications for the use of the tympanic membrane for temperature measurement.
When caring for a client with hyperthermia, the nurse collaborates with other members of the health care team before performing which nursing interventions? Drawing blood cultures Initiating deep breathing and coughing exercises Monitoring intake and output Reducing the temperature in the client's room
Rationale: A physician's order is required for blood cultures. Monitoring intake and output, reducing room temperature, and initiating respiratory exercises are independent nursing actions that do not require collaboration with other members of the health care team.
When assessing a 4-week-old infant, the nurse recognizes early signs of hypothermia by noting which assessment? The infant is shivering. Respirations are rapid and slightly labored. Skin is cool to the touch and pale. Rectal temperature is 33 degrees Celsius.
Rationale: An early sign of hypothermia is a decrease in skin temperature. By the time the core temperature (represented by rectal temperature) decreases, the metabolic rate has already increased in an attempt to maintain temperature and this would be a late sign. Infants rarely shiver and this would be a very late sign, if noted, because they use nonshivering mechanisms of temperature control. Altered respirations would be a late sign indicating that the infant is no longer able to compensate, core temperature is decreasing, and the infant is in distress.
The nurse is caring for an older client admitted with a core body temperature of 34.2 degrees Celsius following prolonged exposure to cold. When creating the plan of care for this client, the nurse would choose which of the following outcomes? The client will maintain skin that is warm. The client will wear an extra sweater and foot covering. The client will report thermal comfort. The client will maintain home environmental temperature at 74°F.
Rationale: Early signs of hypothermia include shivering and piloerection. If the client learns to report and respond to these early signs of hypothermia, more severe hypothermia can be prevented. The clothing the client wears depends on the environmental temperature, so a broad sweeping statement of what the client should wear would be inappropriate; however, an outcome stating "The client will dress appropriately for the environment" would be acceptable. Skin temperature is only a reflection of surface temperature, not core temperature, so an outcome of maintaining warm skin temperature would not be appropriate. Home environmental temperature settings are based on a wide variety of factors from family preference to financial situation, so this may not be an appropriate outcome and can only be evaluated by the home care nurse.
The nurse in the post-anesthesia care unit is caring for a postoperative client with a history of malignant hyperthermia. The nurse notifies the anesthesiologist as soon as which factor is noted? Oxygen saturation of 100% Respiratory rate of 8 breaths per minute Temperature of 99.2°F axillary Increased end-title carbon dioxide levels
Rationale: Early symptoms of malignant hyperthermia are often a rise in both temperature and carbon dioxide levels. A mild temperature elevation postoperatively (99. 2°F) is a common reaction to tissue trauma and would not require notification of the anesthesiologist. Respiratory rate may or may not be affected in the early stages of malignant hyperthermia. If affected, respiratory rate would be more likely to increase as the body tries to eliminate excess carbon dioxide. Oxygen saturation of 100% would be desirable and within normal limits.
The nurse is caring for a client diagnosed with a Staphylococcus aureus septicemia. When planning care for this client what will the nurse assesses? Remittent fever. Heat exhaustion. Fever spikes. Intermittent fever.
Rationale: Fever spikes can be seen in many different types of illness but are particularly likely in clients diagnosed with a bacterial septicemia. They are manifested by rapid rises from normal levels in temperature, which then return to normal levels in a few hours. Intermittent fevers are alternating temperatures that occur at regular intervals. Remittent fevers are frequently seen with viral infections such as colds or influenza. Heat exhaustion is a condition caused by exposure to excessive heat and dehydration causing a fever of 101-102 degrees Fahrenheit.
While caring for an 80-year-old client on the medical unit, the nurse learns from the spouse that the client sets the thermostat in the home at 64°F in order to reduce the monthly heating bill. The nurse includes factor in the client's teaching plan? Assessment for hypothermia The importance of removing throw rugs to prevent falls Social services referral Strategies to reduce the risk of hypothermia
Rationale: If the client is keeping the environmental temperature 6 degrees below recommended minimums, it is important that the nurse provide strategies for preventing hypothermia because the client is already at risk secondary to age. While removing throw rugs is a safety precaution, there is nothing in the question to indicate this risk exists. A social services referral may be indicated, but this would not be included in the teaching plan. There is no need to assess a client for hypothermia while the client is in the hospital, but this may be important if home care nurses visit after the client is discharged.
The nurse is caring for a full-term newborn and prepares to give the infant a bath. Which would indicate an understanding of thermoregulation? Bathe the infant quickly when the core temperature is normal and then place the baby under a radiant warmer until the hair dries. Place the newborn on a towel next to the sink and provide a sponge bath without immersing the baby in water. Immerse the baby in warm water until bathing is completed. Avoid bathing the newborn to prevent hypothermia.
Rationale: The newborn should be bathed quickly and efficiently. Afterward the baby should be kept as covered and dry as possible, and then placed under a radiant warmer until the hair dries and normal temperature is obtained to prevent further loss of heat. Placing the infant on a towel on a cold counter while bathing would not reduce conduction, convection, or radiation heat loss. Newborns cannot be immersed in water until after the umbilical cord falls off, and the greatest risk of hypothermia occurs after the infant is removed from the water, not during the immersion. Bathing the newborn is important in order to reduce the risk of infection so avoiding the bath is not appropriate; but the bath must be performed in a manner that reduces the risk of hypothermia.
The nurse is teaching parents how to care for their child's fever at home and recognizes that further teaching is needed when the parents state: "We will check the temperature every 4-6 hours even during the night." "We will call the doctor immediately if the temperature is higher than 104.2°F, and the child has any breathing difficulty." "We will keep the child in summer pajamas while the temperature is high." "We will put the child into a tepid bath as soon as the fever gets too high and then administer the fever medication as soon as the child gets out of the tub."
Rationale: The parents should administer the antipyretic before placing the child in the tepid bath in order for the medication to begin lowering the temperature, using the bath water as an adjunctive therapy. If the parents wait until after the bath to administer the antipyretic, the temperature is unlikely to remain low once the child is dried off. The other statements reflect correct information.
The nurse is caring for an adult client who is shivering. When assessing the client, the nurse finds a temperature of 99.8 degrees Fahrenheit orally and observes chills, goose-bumps, and pale skin that is cool to the touch; the other vital signs are within normal limits. What is the nurse's priority intervention? Apply extra blankets. Encourage warm fluids. Administer an antipyretic medication. Reduce the room temperature.
Rationale: This client is in the chill phase of fever and will most likely have a much higher temperature within 30 minutes so rechecking the temperature is indicated. In the meantime, covering the client with blankets to reduce shivering, which will raise body temperature, is the priority intervention. Once the client stops shivering, blankets should be removed one at a time unless shivering recurs. Only when the client's temperature is elevated above 101 degrees Fahrenheit would the nurse administer an antipyretic. Reducing the room temperature would increase chilling. Administering warm fluids would cause a further increase in core temperature.
The nurse admits a premature newborn born at 32 weeks gestation. Which factor would be a priority nursing intervention for this client? Provide a neutral thermal environment. Teach parents newborn care. Promote bonding between infant and parents. Administer immunizations.
Rationale: Upon admission to the nursery, the priority nursing intervention for the premature newborn is to provide a neutral thermal environment because hypothermia can promote respiratory distress, feeding problems, and other serious complications. While bonding, immunizations, and newborn care will all need to be addressed, they do not take priority over the interventions aimed at preventing hypothermia.
A nurse is caring for 62-year-old Hank Farry, a homeless man who was brought to the emergency department by ambulance gurney after being found acting confused outside a popular restaurant. Mr. Farry is dressed in a short-sleeved shirt, wet pants, shoes, and socks. The nurse notes that the weather outside has been very cold and it rained last night. The nurse notes areas of frostbite on Mr. Farry's nose, ears, and hands. Mr. Farry's healthcare provider suspects that Mr. Farry has superficial frostbite. What additional clinical manifestation will the nurse note if Mr. Farry has superficial frostbite? Stiffness of affected areas Presence of gangrene Yellow appearance of affected areas White appearance of affected areas
Superficial frostbite causes a white appearance of affected areas. A yellow appearance, stiffness, and presence of gangrene occur with deeper frostbite.
Which type of body temperature changes in response to the environment? Metabolic Surface Core Physiologic
Surface temperature changes in response to the environment. Core temperature remains constant and stays within a specific range. Metabolic and physiologic are not types of body temperature.
Which body temperature should be reported to a healthcare provider? 36°C 37.5°C 37°C 37.7°C
The client or family member should notify the healthcare provider if the client's temperature is 37.7degrees°C (100degrees°F) or higher. Temperatures between 36degrees°C and 37.5degrees°C are within the normal range.
Which factor will the nurse consider during the health history aspect of the nursing assessment for a client with hypothermia? Blood pressure Heart rate Skin color Medications
The client's current medication regimen will be considered during the health history aspect of the nursing assessment for a client with hypothermia. Skin color, blood pressure, and heart rate will be considerations of the physical exam of the nursing process.
Which body structure regulates temperature? Hypothalamus Blood vessels Muscles Macrophages
The hypothalamus regulates body temperature. Muscles help to raise body temperature by contracting to increase body heat. Blood vessels dilate or constrict to either save or release body heat. Macrophages release pyrogens in response to pathogens in the body.
A nurse is caring for 82-year-old Betty Thomas, who has been admitted to the hospital with a right hip fracture after a ground-level fall at home. Mrs. Thomas is recently widowed and lives at home alone. Mrs. Thomas's adult daughter went to visit her mother and found her lying on her outdoor patio. Mrs. Thomas tells her daughter that she fell about 12 hours ago and spent the night outside, unable to move. Upon assessment, the nurse notes areas of frostbite to Mrs. Thomas's left ear, nose, and feet. Which clinical therapy will the nurse implement in the collaborative care of Mrs. Thomas's frostbite? Avoid handling affected areas after rewarming. Protect and cover blisters, if present, to avoid tissue damage Massage the affected areas to increase blood flow. Place affected areas in the dependent position.
The nurse should avoid handling affected areas after rewarming to avoid further tissue damage. The nurse should elevate affected areas and avoid massage or rubbing to prevent further tissue damage. Blisters should be debrided, not covered, if present.
Which intervention should the nurse use for the client with hypothermia and frostbite? Treat the affected area for 20dash-30 minutes in circulating warm water. Keep blisters intact, if possible. Massage affected areas to increase blood flow. Place the affected area in a basin of standing warm water.
The nurse should treat the affected area for 20dash-30 minutes in circulating warm water, heated to 40°dash-40.5°C (104°dash-105°F). The nurse should not massage affected areas, as this can lead to further tissue and vascular damage. The nurse should debride blisters, using whirlpool therapy as necessary.
A nurse is caring for Emma Gallagher, a full-term newborn girl who was born by cesarean delivery 30 minutes ago. The nurse is performing a newborn assessment and notes that Emma's core body temperature is slightly subthermic. The nurse swaddles Emma, places a cap on her head, and places Emma in a neutral thermic environment (NTE) in the nursery. What additional factor will the nurse monitor that is directly related to cold stress in the newborn? Potassium level, as ordered Feeding activity Muscular activity Blood glucose level, as ordered
The nurse will monitor Emma's blood glucose level, as ordered, as hypoglycemia is an indicator of cold stress in the newborn. Potassium level will not be monitored. The nurse will also monitor Emma's muscular and feeding activities; however, these are not directly related to cold stress in the newborn.
Which nursing intervention is appropriate in caring for a newborn or infant with hypothermia? Rapidly rewarm the child when necessary. Undress the newborn and place in a radiant warmer. Maintain a neutral thermal environment. Maintain a very warm thermal environment.
When caring for a hypothermic newborn or infant, the nurse should maintain a neutral thermal environment (NTE) and warm the child slowly. The nurse should not undress the newborn and place in a radiant warmer; rather, the nurse should swaddle the newborn and cover the scalp.
How does the body regulate temperature when the skin is chilled? (Select all that apply.) Sweating inhibition Hormone production Shivering Vasodilation Vasoconstriction
When the skin is chilled, the body attempts to regulate temperature by shivering to increase heat production. The body inhibits sweating to decrease heat loss. In addition, the body performs vasoconstriction to reduce heat loss. Vasodilation would increase heat loss. Hormones are not produced as a temperature regulating mechanism within the body.
How does the body regulate temperature when the skin is chilled? (Select all that apply.) Sweating inhibition Shivering Vasodilation Vasoconstriction Hormone production
When the skin is chilled, the body attempts to regulate temperature by shivering to increase heat production. The body inhibits sweating to decrease heat loss. In addition, the body performs vasoconstriction to reduce heat loss. Vasodilation would increase heat loss. Hormones are not produced as a temperature regulating mechanism within the body.
During a home visit, the nurse becomes concerned with the care a 6-year-old child with chicken pox is receiving from the mother. What did the nurse observe the mother perform? Provided the child with aspirin for a fever Played a game with the child in the child's bedroom Applied topical medication to reduce itchiness from the rash Encouraged the child to drink more fluids
Rationale: Acetylsalicylic acid, or aspirin, should be avoided in children under the age of 18 due to the increased risk of developing Reye syndrome, particularly in children with the flu virus and varicella infections. Encouraging fluids is a positive measure. Playing with the child is a positive action. Applying topical medication to reduce itchiness is a positive measure.
A college student, who is brought to the emergency department by his girlfriend, has a body temperature of 94.8°F. Which question should the nurse ask the girlfriend to help determine the client's condition? "When did you find him?" "How long was he outside?" "Was he drinking alcohol?" "Where did you find him?"
Rationale: Modifiable risk factors for the development of hypothermia include ingestion of alcohol and other substances. The nurse needs to learn if the client was drinking alcohol. The location of the client, the time the client was found, and the length of time the client was exposed are not as important as knowing whether the client has ingested alcohol.
From an assessment of vital signs, the nurse learns that a homeless client has a body temperature of 96.2degrees°F. What actions should the nurse take? (Select all that apply.) Provide oral hygiene. Administer a tepid sponge bath. Provide warm oral fluids. Cover the head with a cap. Cover with a warmed blanket.
Rationale: Nursing actions for a client with hypothermia include providing warm oral fluids, covering the head with a cap, and covering the client with a warmed blanket. Oral hygiene and a tepid sponge bath are interventions appropriate for a client experiencing hyperthermia.
A client is brought by ambulance to the emergency department with suspected heat exhaustion. Which temperature measurement approach should the nurse use to quickly obtain the client's core temperature? Axillary Tympanic membrane Rectal Oral
Rationale: The client's core temperature can be measured very quickly using the tympanic membrane. The oral, rectal, and axillary routes are not as efficient in measuring core temperature.
