Nursing - Thermoregulation

A person sustains severe burns of the arms and is waiting for emergency services to arrive. A nurse bystander responds to the scene. Another bystander is getting ready to apply butter to the burns, stating that it will provide soothing relief. An appropriate response by the nurse is, "I wouldn't advise putting the butter on. Our focus should be on

... covering up the victim with one of those tablecloths.

The nurse has initiated an intravenous antibiotic on a client with hyperpyrexia and diminished urine output. The nurse concludes that the probable cause of the diminished urine output is:

A compensatory response to fever

A 6-year-old boy is sent to the school nurse on a snowy below-freezing day because he arrived without a coat, wearing shorts, a T-shirt, and sandals. What is the first nursing intervention?

Checking the child for frostbite

A client's temperature is 100.4° F 12 hours after a spontaneous vaginal birth. What does the nurse suspect is the cause of the increased temperature?

Dehydration

What are the initial nursing actions after the birth of a preterm baby with an Apgar score of 6?

Drying the infant and placing the infant in a warm controlled environment

Immediately after birth, a newborn is dried before being placed in skin-to-skin contact with the mother. What type of heat loss does this intervention prevent?

Evaporation

Soon after admission to the hospital with a head injury, a client's temperature increases to 102.2° F (39° C). The nurse considers that the client has sustained injury to what structure?

Hypothalamus

While assessing a term infant a few hours after birth, the nurse finds a body temperature of 95.5° F. What does the nurse do in this situation?

Keep the infant in a double-walled incubator for a few hours

A parent of a preterm infant asks a nurse in the neonatal intensive care unit why the baby is in a bed with a radiant warmer. The nurse explains that preterm infants are at increased risk for hypothermia because they

Lack the subcutaneous fat that usually provides insulation

The nurse is measuring the body temperature of four neonates born at term in a pediatric health setting. Which neonate has normal body temperature?

Neonate 3 The normal body temperature of term neonates is in the range of 36.5° to 37.5° C. Therefore, a body temperature of 37.1° C is a normal finding. The body temperatures of 35.5° C and 36.0° C in neonates 1 and 2 indicate hypothermia. The body temperature of 38.5° C in neonate 4 indicates hyperthermia

A client has been diagnosed with hyperthyroidism. The nurse expects the client to exhibit which clinical manifestations? Select all that apply

Nervousness Increased appetite

A nurse assesses the vital signs of a 50-year-old female client and documents the results. Which of the following are considered within normal range for this client? Select all that apply.

Oral temperature of 98.2° F Apical pulse of 88 beats per minute and regular Blood pressure of 116/78 mm Hg while in a sitting position

The nurse is reassessing a newborn who had an axillary temperature of 97° F (36° C) and was placed skin to skin with the mother. The newborn's axillary temperature is still 97° F (36° C) after 1 hour of skin-to-skin contact. Which intervention should the nurse implement next?

Placing the newborn under a radiant warmer in the nursery

A preterm neonate is receiving oxygen by way of an overhead hood. What should the nurse do to protect the infant under the oxygen hood?

Put a hat on the infant's head to avoid hypothermia

On the day after surgery for insertion of a ventriculoperitoneal shunt to treat hydrocephalus, an infant's temperature increases to 103.0° F (39.4° C). The nurse immediately notifies the practitioner. What is the next nursing action?

Removing excess clothing from the infant

During the assessment of a preterm neonate the nurse determines that the infant is experiencing hypothermia. What should the nurse do?

Rewarm gradually

After surgery a client's fever does not respond to antipyretics. The health care provider prescribes that the client be placed on a hypothermia blanket. A response to hypothermia therapy that the nurse should prevent is:

Shivering

While assessing a newborn, the nurse notes that the skin is mottled. What should the nurse do first?

Warm the environment.

What is the nurse's initial action immediately after assisting with a precipitous birth in the triage area of the emergency department?

Warming the newborn

After surgery for insertion of a coronary artery bypass graft (CABG), a client develops a temperature of 102° F (38.8° C). What priority concern related to elevated temperatures does a nurse consider when notifying the health care provider about the client's temperature?

A fever increases the cardiac output

A client with multiple myeloma who is receiving chemotherapy has a temperature of 102.2° F. The temperature was 99.2° F when it was taken six hours ago. A priority nursing intervention is to:

Administer the prescribed antipyretic and notify the primary health care provider

A health care provider prescribes the application of a warm soak to an intravenous (IV) site that has infiltrated. What principle does the nurse determine is in operation when the application of local heat transfers temperature to the body?

Conduction

A client with hypothermia is brought to the emergency department. What treatment does the nurse anticipate?

Core rewarming with warm fluids

Which is a characteristic of the glands that secrete a thick substance in response to emotional stimulation and become odoriferous due to bacterial action?

Grow in conjunction with axillary hair follicles

A nurse must continually assess a preterm infant's temperature and provide appropriate nursing care because, unlike the full-term infant, the preterm infant:

Has a limited supply of brown fat available to provide heat

A client gives birth to a full-term male with an 8/9 Apgar score. What should the immediate nursing care of this newborn include?

Identifying the infant, assessing respirations, and keeping him warm

A nursing instructor provides education for the students on thermoregulation in the nursery. The students determine that in the healthy full-term neonate, heat production is accomplished by:

Metabolism of brown fat

A preterm infant is receiving oxygen from an overhead hood. What nursing care is required while the infant is under the hood?

Putting a hat on the infant's head

A nurse is caring for a mother and neonate. What is the priority nursing action to prevent heat loss in the neonate immediately after birth?

Putting the naked newborn on the mother's skin and covering the infant with a blanket

An unresponsive older adult is admitted to the emergency department on a hot, humid day. The initial nursing assessment reveals hot, dry skin, a respiratory rate of 36 breaths/min, and a heart rate of 128 beats/min. What is the initial nursing action?

Remove the clothing.