thermoregulation
A nurse is about to give a full-term neonate their first bath. How should the nurse proceed? -Bathe the neonate only after vital signs have stabilized. -Clean the neonate with medicated soap. -Scrub the neonate's skin to remove the vernix caseosa. -Wash the neonate from feet to head.
Bathe the neonate only after vital signs have stabilized. To guard against heat loss, the nurse should bathe the neonate only after vital signs have stabilized. To avoid altering the skin pH, the nurse should use only mild soap and water. Scrubbing should be avoided because it may cause abrasions through which microorganisms can enter. The nurse should wash the neonate from head to feet.
The nurse is preparing to administer acetaminophen to a 4-year-old child to provide comfort. Which precaution is specific to antipyretics? -Check for medicine allergies -Take entire course of medication -Ensure proper dose and interval -Warn of possible drowsiness
Ensure proper dose and interval It is very important to ensure that the proper dose is given at the proper interval because an overdose can be toxic to the child. Concerns with allergies and taking the entire, prescribed dose are precautions when administering antibiotics and all medications. Drowsiness is not a side effect of antipyretics.
A 9-month-old baby is scheduled for heart surgery. When preparing this client for surgery, the nurse should consider which surgical risk associated with infants? -Prolonged wound healing -Potential for hypothermia or hyperthermia -Congestive heart failure -Gastrointestinal upset
Potential for hypothermia or hyperthermia Infants have difficulty maintaining stable body temperature during surgery because the shivering reflex is not well developed, making hypothermia or hyperthermia more likely. They are not at an increased risk for prolonged wound healing, congestive heart failure, or gastrointestinal upset.
Fever and hyperthermia describe conditions in which body temperature is higher than the normal range. When does hyperthermia occur? -When the body temperature is 39.5°C (103.1°F) -When the body's set point is unchanged, but the temperature goes up -When the body's set point changes to a higher set point -When body temperature is greater than 37.6°C (99.7°F)
When the body's set point is unchanged, but the temperature goes up Hyperthermia occurs when the set point of the body is unchanged, but the mechanisms that control body temperature are ineffective in maintaining body temperature within a normal range during situations when heat production outpaces the ability of the body to dissipate that heat. A body temperature of either 37.6°C or 39.5°C is considered a fever, the same as when the set point of the body is raised.
The nurse assesses that a client is shivering. Which intervention is most appropriate to prevent further stress on the body? -applying a cooling blanket -applying a blanket -raising the room temperature -providing warm fluids
applying a blanket Covering prevents heat loss, and the shivering will not stop until the hypothalamus readjusts to a higher set point. A cooling blanket will make the shivering worse, because it will make the client feel cold. Raising the room temperature warms the body surface and is only appropriate for subnormal temperatures. Warm fluids conduct heat to internal organs and this client is febrile; the goal is to reduce to heat.
Hypothermia may occur as a result of -the infusion of warm fluids. -increased muscle activity. -open body wounds. -being young.
open body wounds Inadvertent hypothermia may occur as a result of a low temperature in the OR, infusion of cold fluids, inhalation of cold gases, open wounds or cavities, decreased muscle activity, advanced age, or particular pharmaceutical agents.
A client postoperative from an appendectomy reports feeling cold and has a temperature of 96.2°F (35.7°C). Which action should the nurse perform first? -Check the client's blood pressure. -Apply an oxygen saturation monitor. -Apply warm blankets to the client. -Notify the health care provider.
Apply warm blankets to the client. The nurse should apply warm blankets to the client because the client is hypothermic with a temperature of 96.2°F (35.7°C). The client can be assessed further by checking vital signs and using an oxygen saturation monitor. The health care provider should be notified about the client's temperature but an intervention should be done first to ensure the client begins warming immediately.
A nurse in the emergency department admits a male client who has experienced severe frostbite to his hands and toes after becoming lost on a ski hill. The nurse recognizes that which phenomena has contributed to his tissue damage? -Decreased blood viscosity has resulted in interstitial bleeding. -Reactive vasodilation has compromised perfusion. -Autonomic nervous stimulation has resulted in injury. -Decreased blood flow has induced hypoxia.
Decreased blood flow has induced hypoxia. Damage from exposure to cold results from hypoxia, ice crystal formation, and vasoconstriction. Blood viscosity increases, not decreases, and vasoconstriction rather than vasodilation occurs.
A client experiencing an increased temperature reports weakness and fatigue. Which explanation accurately accounts for these symptoms? -Epinephrine and norepinephrine shift the body metabolism to heat production rather than energy generation. -Sympathetic nervous system responses to changes in core temperature and environmental temperature occur. -Insensible perspiration, which diffuses water through the skin, is greatest in a dry environment. -Increased blood volume occurs as a means of dissipating heat as the body compensates.
Epinephrine and norepinephrine shift the body metabolism to heat production rather than energy generation. Epinephrine and norepinephrine are used by the body to produce heat and not energy, which leaves the client feeling weak and fatigued. All the other options apply to heat loss rather than heat production.
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? -Generalized muscle pain -Pulse 90 beats per minute -Temperature 40 degrees C (104 degrees F) -Muscle weakness
Temperature 40 degrees C (104 degrees F) Malignant hyperthermia is a life-threatening condition that may occur after use of a nondepolarizing neuromuscular junction blocker. When prioritizing care, safety issues should be treated first, followed by the ABCs as outlined by Maslow.
Nonshivering thermogenesis occurs in which of the following to help the newborn infant fight hypothermia? -Brown fat -Adipose tissue -Subcutaneous tissue -Epidermis
brown fat Nonshivering thermogenesis occurs in the liver, brown fat tissue, and the brain and helps the newborn infant fight hypothermia.
The nurse is caring for a client who experienced damage to the midbrain during neurologic surgery. The nurse will expect the client to exhibit what sign? -chronic insomnia -sensorineural hearing loss -difficulty in distinguishing hot and cold -slurred speech
difficulty in distinguishing hot and cold The thalamus, located in the midbrain, is responsible for temperature control. The client will have difficulty distinguishing hot and cold. Centers of control for sleep and hearing are found in the hindbrain, and areas that control speech and communication are found in the forebrain.
A client in the operating room goes into malignant hyperthermia due to an abnormal reaction to the anesthetic. The nurse knows that the area of the brain that regulates body temperature is what? -Cerebellum -Thalamus -Hypothalamus -Midbrain
hypothalamus The hypothalamus plays an important role in the endocrine system because it regulates the pituitary secretion of hormones that influence metabolism, reproduction, stress response, and urine production. It works with the pituitary to maintain fluid balance through hormonal release and maintains temperature regulation by promoting vasoconstriction or vasodilatation. In addition, the hypothalamus is the site of the hunger center and is involved in appetite control.
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 slow but steady pulse -A weak and thready pulse -A slow and imperceptible pulse
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.
The nurse is taking a rectal temperature on a client who reports feeling lightheaded during the procedure. What would be the nurse's priority action in this situation? -Leave the thermometer in and notify the physician. -Remove the thermometer and assess the blood pressure and heart rate. -Remove the thermometer and assess the temperature via another method. -Call for assistance and anticipate the need for CPR.
Remove the thermometer and assess the blood pressure and heart rate. Vagal nerve stimulation may occur when obtaining a rectal temperature. Vagal nerve stimulation can cause the pulse and blood pressure to drop significantly, causing the client to feel lightheaded; therefore, the thermometer should be removed immediately and the pulse and blood pressure assessed. The physician can be called after assessing the client. The temperature is not the priority at this time. Assistance for CPR would be determined if the client's condition worsens.
A nurse caring for an older adult who has been diagnosed with a urinary tract infection checks the client's temperature on admission and finds that it is 96.6°F (35.9°C). Which statement describes how the nurse should interpret the finding? -The client's temperature is normal so the client does not have an infection. -The client is exhibiting a normal febrile response to a urinary tract infection. -The client may be exhibiting a blunted or absent febrile response. -The client's absent febrile response indicates absence of an infection.
The client may be exhibiting a blunted or absent febrile response. The nurse should interpret the finding as a blunted or absence febrile response to the infection. It has been suggested that as many as 30% of older adults with serious infections present with absent or blunted febrile response, and this may delay diagnosis and initiation of antimicrobial treatment.
A client with a history of malignant hyperthermia is scheduled for surgery. Which agent would the nurse most likely expect to administer? -Botulinum toxin type B -Dantrolene -Baclofen -Methocarbamol
dantrolene Dantrolene is the drug that would be used as prevention and treatment of malignant hyperthermia.
A patient receiving succinylcholine experiences malignant hyperthermia. What drug is used to treat this condition? -Acetylsalicylic acid -Pyridostigmine -Phenobarbital -Dantrolene
dantrolene Dantrolene, a muscle relaxant, is the drug of choice to treat malignant hyperthermia. Pyridostigmine is the antidote for nondepolarizing NMJ toxicity. Phenobarbital and acetylsalicylic acid would not treat malignant hyperthermia.
When assessing a neonate 1 hour after birth, the nurse notes acrocyanosis of both feet and hands, measures an axillary temperature of 95.5°F (35.3°C), an apical pulse of 110 beats/minute, and a respiratory rate of 64 breaths/minute. Which assessment would be the most concerning for the nurse? -hypothermia -tachycardia -bradypnea -hypoxia
hypothermia The neonate's normal axillary temperature should range from approximately 97.7°F to 99.5°F (36.5°C to 37.5°C). A temperature of 95.5°F (35.3°C) is very low. When the temperature drops, the neonate is at risk for hypothermia, respiratory distress, and hypoglycemia. The normal respiratory rate for a newborn is 30 to 60 breaths/minute while resting. It can increase with crying, and it will increase if hypothermia develops. This neonate would have tachypnea instead of bradypnea. The normal heart rate for a newborn is 110 to 160 beats/minute, so 110 beats/minute would be a normal finding and not tachycardia. All neonates have acrocyanosis of the hands and feet in the first few hours of life; this would not indicate hypoxia.
While sponging a client who has a high temperature, the nurse observes the client begins to shiver. At this point, the priority nursing intervention would be to: -administer an extra dose of aspirin. -stop sponging the client and retake a set of vital signs. -increase the room temperature by turning off the air conditioner and continue sponging the client with warmer water. -place a heated electric blanket on the client's bed.
stop sponging the client and retake a set of vital signs. Modification of the environment ensures that the environmental temperature facilitates heat transfer away from the body. Sponge baths with cool water or an alcohol solution can be used to increase evaporative heat losses. More profound cooling can be accomplished through the use of a cooling blanket or mattress, which facilitates the conduction of heat from the body into the coolant solution that circulates through the mattress. Care must be taken so that cooling methods do not produce vasoconstriction and shivering that decrease heat loss and increase heat production.
The nurse is teaching an in-service program to a group of nurses on the topic of children diagnosed with rheumatic fever. The nurses in the group make the following statements. Which statement is mostaccurate regarding the diagnosis of rheumatic fever? "This disorder is caused by genetic factors." "Children who have this diagnosis may have had strep throat." "Being up-to-date on immunizations is the best way to prevent this disorder." "The onset and progression of this disorder is rapid."
"Children who have this diagnosis may have had strep throat." Rheumatic fever is precipitated by a streptococcal infection, such as strep throat, tonsillitis, scarlet fever, or pharyngitis, which may be undiagnosed or untreated. Rheumatic fever is a chronic disease of childhood, affecting the connective tissue of the heart, joints, lungs, and brain. There is no immunization to prevent rheumatic fever. The onset of rheumatic fever is often slow and subtle.
The nurse is explaining to a group of nursing students the proper technique for obtaining an accurate temperature on a child. The instructor determines the session is successful when the students correctly choose which factor related to taking a temperature? -"A rectal temperature is usually 0.5° to 1.0° lower than the oral measurement." -"Tympanic temperatures should not be taken on a child who is sleeping." -"An axillary temperature usually measures 0.5° to 1.0° higher than the oral measurement." -"Rectal temperatures should not be taken on a child with diarrhea."
-"Rectal temperatures should not be taken on a child with diarrhea." A rectal temperature should not be taken in the newborn because of the danger of irritation to the rectal mucosa or in children who have had rectal surgery or who have diarrhea. A rectal temperature is usually 0.5° to 1.0° higher than the oral temperature and the axillary temperature is usually 0.5° to 1.0° lower than the oral temperature. It is easier to obtain a tympanic temperature in a sleeping child as the temperature can be obtained without walking them up.
On what client would it be appropriate for the nurse to perform a rectal temperature? -A newborn infant during the initial assessment -A toddler who is admitted with rotavirus and frequent diarrhea -A child who has suffered a head injury and is comatose -A post-cardiac surgery patient
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.
A client is admitted with frostbite. What will the nurse tell the client about the changes that have occurred due to cold exposure? -Cold causes vasodilation and redness. -Cold increases blood viscosity and thrombosis. -Cold increases the speed of blood flow through vessel. -Cold exposure results in hypertrophy of cells in the affected area.
Cold increases blood viscosity and thrombosis. Cold temperature exposure causes increased blood viscosity and can cause clots to form. Vasoconstriction is induced, and the flow of blood is slowed due to this. Cells do not hypertrophy in response to temperature change.
A surgical client is at greatest risk for hypothermia during a surgical procedure related to: -impaired thermoregulatory mechanisms brought on by anesthesia. -negligence of the anesthesiologist in regulating the body temperature. -the decreased temperature of the surgical suite caused by electrical appliances. -the instillation of warmed intravenous fluids that lower the core temperature.
impaired thermoregulatory mechanisms brought on by anesthesia. A surgical client has a higher risk of hypothermia related to impaired thermoregulatory mechanisms brought on by anesthesia and other drugs. The instillation of warmed intravenous fluids is used to increase the core temperature, not lower it. The remaining options related to room temperature and the regulation of body temperature are not relevant.
Which term indicates a potentially serious client condition? -pyrexia -pulse pressure -eupnea -afebrile
pyrexia Pyrexia means an increase above normal in body temperature. Pulse pressure is an objective term related to the pulse. Eupnea means a normal breathing pattern. Afebrile means that the body temperature is not elevated.
The nurse needs to assess a 1-year-old child for fever. Which approach will produce the most accurate reading? -Rectal -Oral -Forehead -Axillary
rectal Measurement of core body temperature is important when evaluating fever. The rectal route is considered the most accurate. In adults and older children, the oral route is lower, but still accurate; however, in young children the oral route may be unreliable. Forehead thermometers can predict trends, but are not as accurate as other routes. The axillary route requires up to 10 minutes for the temperature to register appropriately.
A nurse is teaching new parents about keeping follow-up appointments and calling their health care provider if they notice signs of illness in their newborn. The nurse determines that the teaching was successful when the parents identify which signs as needing to be reported? Select all that apply. -temperature of 38.3° C (101° F) or higher -refuse feeding -abdominal distention -general fussiness -approximately eight wet diapers a day
refuse feeding temperature of 38.3° C (101° F) or higher abdominal distention Parents should call their health care provider if they note any of the following warning signs: temperature of 38.3° C (101° F) or higher; forceful, persistent vomiting; refusal to take feedings; two or more green, watery diarrheal stools; infrequent wet diapers and change in bowel movements from normal pattern; lethargy or excessive sleepiness; inconsolable crying and extreme fussiness; abdominal distention; or difficult or labored breathing.
