Thermoregulation
When assessing an infant's auxiliary temperature, it will be:
1*F(0.5*C) lower than an oral temperature.
A nurse has administered a prescribed dose of acetaminophen to a hospitalized client with a fever. This medication will reduce the client's temperature by what means?
Acting directly on the hypothalamus to cause vasodilation and sweating
The nurse is caring for an intraoperative client whose temperature has increased suddenly to 103.2°F (39.6°C). What immediate intervention should the nurse anticipate?
Administration of dantrolene
Which statement about temperature regulation and skin is accurate?
Arteriovenous anastomoses between an artery and a vein within the skin layer are important for temperature regulation.
The nurse walks into a clients room and notes a small fan blowing on the mother as she holds her infant. The nurse should explain this can results in the infant losing body heat based on which mechanism?
Convection
A newborn is placed in an open crib in the newborn nursery, which is located near the doorway to the hall. What type of heat loss would this infant experience?
Convective
Which procedure uses liquid nitrogen to freeze tissue, thereby destroying cells?
Cryoablation
During surgery to repair a ruptured Achilles tendons, the client develops severe muscle contractions and dramatic rise in body temperature. Which medication will be administered?
Dantrolene Sodium
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.
Upon entering the room of the newborn and parents, the nurse notes that the diapered newborn is undressed and laying on the foot of the bed while the parents plan which outfit to place on the baby. What is the priority for the nurse?
Explain the need to keep the newborn wrapped or dressed to prevent cold stress.
The parents are bonding with their newborn when the nurse notes the infant's axillary temperature is 97.2oF (36.2oC) an hour after birth. Which intervention should the nurse prioritize for this family?
Help the mother provide kangaroo care.
Which assessment and laboratory findings would be most closely associated with acute leukemia?
High blast cell counts and fever
The hypothalamus is responsible for regulating which functions? (Select all that apply.)
Hunger Blood Pressure Reproduction
Which is associated with an increase in gonadotropin-releasing hormone secretion?
Increased light exposure
A 20-year-old female has been brought to the emergency department from a rave party where she collapsed on the dance floor. Her friends acknowledge that the woman took ecstasy early in the evening. Her heart rate is regular at 89 beats/minute; temperature 39.8°C (103.6°F) orally. The emergency team would recognize that which phenomenon, related to the drug, is a likely contributor to the woman's status?
Increased peripheral vasoconstriction
Nursing assessment findings reveal a temperature of 96.2*F, pulse oximetry 90%, shivering and client complains of chilling. The findings are indicative of which nursing diagnosis?
Ineffective thermoregulation
The cremaster muscles work in concert with the Pam pink form plexus that surrounds the testicular artery to:
Maintain testicular temperature
Which intervention should a nurse implement to promote thermal regulation in a preterm newborn?
Observe for clinical signs of cold stress such as weak cry
What helps to generate heat when the core body temperature is too low?
Pilot reaction
An emergency nurse working in a military hospital admits a new military recruit who collapsed during a heavy training exercise in the desert. The skin is moist, the pulse is 120 beats/minute, and the respirations are 28/minute. What interventions will the nurse implement? Select all that apply.
Provide fluid resuscitation. Remove client's heavy clothing. Keep the environment cool.
The nurse notes a newborn has a temperature of 97.0*F (36.1*C) on assessment. The nurse acts to prevent which complication first?
Respiratory distress
Which intervention would be an appropriate action for a nurse to take in attempting to decrease a client's temperature through radiation heat loss?
Set the room to a lower temperature
Which site would be best to use to take the temperature on a 12-month-old infant seen in an emergency room?
Tympanic membrane
In a course of chronic myelogenous leukemia (CML), which clinical manifestations will the client experience in the accelerated phase? Select all that apply.
Weight loss Low-grade fever Abdominal fullness
The nurse examines a 26-week-old premature neonate. The skin temperature is lowered. What could be a consequence of the infant being cold?
apnea
Which endocrine gland is referred to as the body's "master gland"?
hypothalamus
Which hormone is responsible for breast development and the increase in body temperature that occurs with ovulation?
progesterone
Based upon circadian rhythms, when would the nurse note the highest temperature during a 24-hour period?
1700
Which factor would demonstrate physiologic respiratory adaptation to extrauterine life in a newborn infant?
Abrupt temperature change upon delivery, causing a cry
Which signs would a nurse expect in a client diagnosed with serotonin syndrome? Select all that apply.
Agitation Elevated heart rate Elevated temperature
A nurse is teaching a prenatal class and is asked the purpose of amniotic fluid. Which statements are correct? Select all that apply.
Amniotic fluid promotes fetal movement enhancing musculoskeletal development. Sufficient amounts of amniotic fluid cushion the fetus from trauma. Amniotic fluid allows the fetal umbilical cord to be relatively free from compression. Sufficient amounts of amniotic fluid help the fetus maintain a constant body temperature.
The preoperative nurse is caring for a client who is undergoing abdominal surgery with the inclusion of succinylcholine in the client's anesthesia. The anesthesiologist tells the team that the client is exhibiting signs and symptoms suggestive of malignant hyperthermia. What is the nurse's best action?
Anticipate IV administration of dantrolene.
Which structure would likely be present in a hair follicle in a man's groin but not in a follicle on his face?
Apocrine gland
Fever in infants and young children is not an uncommon event. Many trips to the pediatrician's office occur because of fever in children ages 1 day to 3 years. Which sign or symptom does not indicate fever in an infant?
Avid feeding
A 38-year-old male client is brought to hospital by ambulance with mild hypothermia following a prolonged hike in the rain. Which set of vital signs would be most characteristic of the client's diagnosis?
BP 138/84, RR 28, HR 111
The nurse is assessing clients at a clinic. Which signs indicate primary HIV infection
CD4 lymph: above 800 cells/mm³, fever, sore throat, muscle aches, rash
The nurse had admitted a small-for-gestational-age infant (SGA) to the observation nursery from the birth room. Which action would the nurse prioritize in the newborn's care plan?
Closely monitor temperature
A high school football player is brought to the emergency department after collapsing at practice in extremely hot and humid weather. Which of the following would lead the nurse to suspect that the client is experiencing heat stroke?
Delirium
The nurse is assessing a client diagnosed with varicella. The nurse is aware that manifestations may include:
Fever
A normal response to fever is an elevated heart rate. A client with a fever who is not exhibiting an elevated heart rate would indicate to the nurse that the cause of the fever might be:
Legionnaires Disease
A client with schizophrenia started risperidone 2 weeks ago. Today, the client reports feeling flu-like symptoms. The nurse assessment reveals the following 104.4*F , respirations 24 breath/minute, blood pressure 130/102 mmHg, pulse rate 120 beats/min. the nurse also notes muscle stiffness and pain, excessive sweating and salivation, and changes in mental status. The nurse suspects the client is experiencing:
Neuroleptic malignant syndrome
A nurse is caring for a client with fever of unknown origin (FUO). The nurse anticipates that the client may have which underlying condition? Select all that apply.
Non-Hodgkin lymphoma Abscessed infection
A newborn is born diagnosed with an omphalocele. What will the nurse prioritize in the care plan during the preoperative period?
Place the infant in a sterile bowel bag
When educating students about the differences between brown fat versus white fat, the instructor will share that brown fat has iron in its mitochondria that will facilitate:
Production of a protein that releases the energy generated from metabolism as heat
The nurse is caring for a preschooler who has developed a high fever and has just had a seizure. What is the best action by the nurse?
Remove any blankets or heavy clothing and replace with a thin sheet
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?
Remove the thermometer and assess blood pressure and heart rate.
The nurse is caring for a client who had a kidney transplant 4 months ago. What symptom would be indicative of an acute transplant rejection? Select all that apply
Temperature >100.8F Weight gain Increased blood urea nitrogen level
The nurse is caring for a client with traumatic brain injury (TBI). Which clinical finding, observed during the reassessment of the client, causes the nurse the most concern?
Temperature increase from 98.0°F to 99.6°F
When developing a care plan for a client who has recently suffered a stroke, a nurse includes the nursing diagnosis Risk for imbalanced body temperature. What is the rationale for this diagnosis?
The stroke may have impacted the body's thermoregulation centers.
Fever and hyperthermia describe conditions in which body temperature is higher than the normal range. When does hyperthermia occur?
When the body's set point is unchanged, but the temperature goes up
Sweating is mediated by which neurotransmitter?
acetylcholine
The nurse walks into the clients room to pick up the dinner tray and notes the client has not eaten. Which action should the nurse prioritize after noting the client appears sleepy, has perspiration on the forehead, and the face appears flushed?
assess temperature
When caring for a client who is post-intracranial surgery, what is the most important parameter to monitor?
body temperature
A client experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with
body temperature control.
When an infection is bloodborne, the manifestations include which symptom?
chills
When discussing heat loss in newborns, placing a newborn on a cold scale would be an example of what type of heat loss?
conduction
The loss of heat from the body through the circulation of air currents is known as:
convection
Pyrogens are substances that produce fever in the body. Substances such as bacterial products, bacterial toxins, or whole microorganisms enter the body and stimulate the host cells to produce certain mediators. What are these called?
endogenous pyrogens
A nurse notes that a client with a fever has begun to shiver. The nurse should assess for which finding
increased temperature
A 2-month-old infant is admitted to a local health care facility with an axillary temperature of 96.8*F (36*C). Which observed manifestation would confirm the occurrence of cold stress in this client?
lethargy and hypotonia
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
A child is diagnosed with group A streptococcal pharyngitis. The nurse would teach the parents to be alert for signs and symptoms of:
scarlet fever
A client is experiencing anorexia, myalgia, arthralgia, headache, and fatigue. The nurse should assess for:
temperature
An 11-year-old child was recently diagnosed with chickenpox. His parents gave him aspirin for a fever and the child is now hospitalized. Which nursing interventions are appropriate for this child? Select all that apply.
• Request order for anticonvulsant • Request order for an antiemetic • Assess intake and output every shift
The father of a toddler tells the nurse that his child had a fever the previous night. During the assessment, which statement by the father indicates further discussion is necessary regarding temperature measurement?
"My mother said she always used a glass thermometer when i was a kid and it was very accurate. Maybe that would be better."
Parents tell the nurse they have been told to keep their newborn away from windows. They do not understand why this is necessary. Which rationale will the nurse provide to the parents?
"Newborns cannot shiver to produce heat and need to be kept away from sources of heat loss."
A woman who delivered her infant by cesarean section 1 week ago called her physician's office to report chills, fever of 101.*F (38.7*C) and a poor appetite. She also tells the nurse that she is having strong afterbirth pains and her Lockhart has increased in volume and has odor. Lab work shows an elevated WBC count. Which of these reported findings is the most significant finding related to the suspected diagnosis of endometritis?
Fever
An adult client who is currently undergoing rhinoplasty has developed characteristic signs and symptoms of malignant hyperthermia. The operating room nurse should anticipate what intervention?
IV administration of dantrolene sodium
When providing nursing care to older adults, it is most important to provide comfort due to which of the following changes?
Thermoregulation
The nurse is monitoring the client's vital signs and notes: 100.2oF (37.9oC), heart rate 82, respiratory rate 17, and blood pressure 124/78. The client has recently had an epidural. What is the best response when the client's partner asks if she is getting sick?
"The fever may be due to the epidural."
A nurse in the emergency department admits a male client who has experienced sever 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 flow has induced hypoxia.
Age-related changes in the neurologic system must be carefully assessed. Which of the following changes does the nurse expect to find in some degree depending on the patient's age and medical condition? Select all that apply.
Decreased muscle mass Increased sensitivity to heat and cold Reduced papillary responses
Many clients experience a slight fever after birth especially during the first 24 hours. To what should the nurse attribute this elevated temperature?
Dehydration
Which risk factor presents the greatest risk for injury in an older adult client who is experiencing a dysfunction in temperature regulator function?
Delayed initiation of appropriate treatment
The nurse assesses an infant's body temperature as 97.1°F (36.2°C) during an extended resuscitation at birth. What consequence of this temperature would the nurse anticipate? Select all that apply.
Fetal Shunt remain open Anaerobic glycolysis occurs Pulmonary perfusion occurs Metabolism increases
What findings should the nurse report to the health care provider for a postpartum client who delivered 12 hours ago? Select all that apply.
Fundal height level of one fingerbreadth above the umbilicus Temperature of 101.8°F (38.8°C)
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?
Hypothalamus
The nurse is conducting a physical assessment of a homeless man during a night when the wind chill factor is -10*F (-23*C). When assessing the mans fingers and toes for frostbite, the nurse looks for which type of cellular injury?
Hypoxic
A two-day postoperative client's temperature was 98.5°F (36.9°C) at 3:00 pm. At 6:00 pm, the unlicensed assistant (UAP) notifies the nurse that the client's temperature is 102°F (38.9°C). Which action should the nurse take?
Notify the physician
A 3-hour old newborn is assessed and is tachypneic with a respiratory rate of 44. Heart rate is 168, temperature is 97.3°F (36.3°C) and blood glucose is 90. What is the first action the nurse should take?
Place the newborn away from drafts and under a blanket.
A nurse suspects malignant hyperthermia in a patient who underwent surgery approximately 18 hours ago. Which of the following would the nurse identify as a late, ominous sign?
Rapid rise in body temperature
The nurse needs to assess a 1-year-old child for fever. Which approach will produce the most accurate reading?
Rectal
Which site results in measuring a client's core body temperature?
Rectal
A nurse is caring for an adult with fever. The nurse determines that which site is most accurate for obtaining the clients core body temperature?
Rectum
A 54-year-old man presents with a temperature of 38.8°C (101.8°F), a racing heart, fatigue, and an upset stomach after spending an afternoon building a deck on a very hot, humid day. The physician assessing the man is performing a differential diagnosis as part of her assessment. Which finding would suggest fever rather than hyperthermia as a cause of the elevation in the man's temperature?
Shivering
A 30-year-old client would like to try using basal body temperature (BBT) as a fertility awareness method. Which instruction should the nurse provide the client?
Take temperature before rising, and record it on a chart.
Which client manifestation indicates signs of drug fever?
Temperature reaches 40°C (104°F) every afternoon, pulse 76 beats/minute, pruritis
A nurse is conducting a community education program on hyperthermia determines that the participants understand the information when they identify that the heat index is which of the following?
Temperature sensed when temperature and humidity are combined.
The home care nurse is assessing a 37-year-old client's vital signs at rest. Which finding requires nursing intervention?
Temporal temperature 100.8*F (38.2*C)
The client has arrived in the short stay unit for an infusion of iodine-131 tositumomab. Before beginning the infusion, the nurses assesses the client's vital signs and finds the client has a temperature of 101.5*F (38.6*C). What is the nurse's best action?
Treat fever as ordered before beginning the therapy
A nurse is performing an admission assessment on a client who is scheduled for an elective surgery the next morning. When taking vital signs, the nurse finds that the client's temperature is 39.4*C (103*F). What should be the nurse's priority action?
Verbally report the finding immediately to the client's health care provider.
A client taking the typical antipsychotic agent haloperidol experiences neuroleptic malignant syndrome. What nursing intervention is highest priority after stopping the medication?
cooling blanket
Which finding might be seen in a neonate suspected of having an infection?
decreased temperature
The nursing instructor is teaching a class on the structure vital to the development of the fetus. The instruction determines the class is successful when the class correctly chooses which facts concerning amniotic fluid?
helots the fetus regulate body temperature
The nursing instructor is teaching a class on the structures vital to the development of the fetus. The instructor determines the class is successful when the class correctly chooses which facts concerning amniotic fluid?
helps the fetus regulate body temperature
During an assessment of an older adult client, the nurse notes an increase in pulse and respiration rates, and notes that the client has warm skin. The nurse also notes a decrease in the client's blood pressure. Which medical diagnosis may be responsible?
hypovolemia
What areas are mainly responsible for coordinating internal and external responses?
thalamus and hypothalamus
A client who has developed a fever is now reporting a headache. The nurse would recognize this manifestation as a result from the:
vasodilatation of cerebral vessels.
A nurse is teaching a woman how to use the basal body temperature method of contraception. the nurse determines that the teaching was successful when the woman identifies that she should refrain from having sexual intercourse at which time?
3 days after she records a slight drop in her temperature followed by an increase.
The nurse is caring for an adult patient with a normal body temperature. What should the nurse know would be the approximate insensible water loss per day in this patient?
600 mL/day
A 2-year-old child with a 3-day history of diarrhea is brought to the urgent care clinic by the caregiver. The nurse determines the child's axillary temperature is within the normal range based on which finding?
96.6°F (35.8°C)
Many clients experience a slight fever after birth especially during the first 24 hours. To what should the nurse attribute this elevated temperature?
dehydration
A nurse is preparing a presentation for a group of high school athletes about temperature regulation during activity such as practice. When describing the mechanisms of heat loss, which of the following would the nurse identify as primarily responsible when environmental temperatures are very high?
evaporation
A hiker presents to the emergency department with reports of flu-like symptoms—thirst, nausea, and inability to urinate. Upon assessment, it is determined that the client has a rectal temperature of 102.2°F (39°C) and is tachycardic. These symptoms support a diagnosis of:
heat exhaustion
A nurse is assigned to a client with a cardiac disorder. The nurse should question an order to monitor the clients body temperature by which route ?
rectal
The nurse has delegated an unlicensed assistive personnel (UAP) to obtain a temperature reading for a client who has neutropenia. Which route used by the UAP requires immediate intervention?
rectal
A nurse caring for a client with a spinal cord injury knows that control of sweat gland activity and temperature regulation is managed by the direct action of which body system?
sympathetic nervous system
An episiotomy or a cesarean incision requires assessment. Which assessment criterion for skin integrity is not initially noted?
temperature
A nurse is monitoring a premature neonate for development of neonatal sepsis. Which assessment finding is an early sign of neonatal sepsis?
temperature instability
The nurse is taking vital signs on a 6-month-old infant. The caregiver reports that over the past 12 hours, the infant has had vomiting, diarrhea, and has been pulling on the ears. Which method(s) would be appropriate for taking this infant's temperature? Select all that apply.
temporal and axillary