Thermoregulation Concept 10

Checking the child for frostbite

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?

Identifying the infant, assessing respirations, and keeping him warm

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?

Nervousness Increased appetite

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

Hypothalamus

A client with a head injury underwent a physical examination. The nurse observes that the client's temperature assessments do not correspond with the client's condition. An injury to which part of the brain may be the reason for this condition?

Dehydration

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?

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

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.

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

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?

Has a limited supply of brown fat available to provide heat

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

Metabolism of brown fat

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:

Lack the subcutaneous fat that usually provides insulation

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

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

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

The nursery nurse identifies a newborn at significant risk for hypothermic alteration in thermoregulation because the patient is a. large for gestational age. b. low birth weight. c. born at term. d. well nourished.

ANS: B Low birth weight and poorly nourished infants (particularly premature infants) and children are at greatest risk for hypothermia. A large for gestational age infant would not be malnourished. An infant born at term is not considered at significant risk. A well nourished infant is not at significant risk.

The most appropriate measure for a nurse to use in assessing core body temperature when there are suspected problems with thermoregulation is a(n) a. oral thermometer. b. rectal thermometer. c. temporal thermometer scan. d. tympanic membrane sensor.

ANS: B The most reliable means available for assessing core temperature is a rectal temperature, which is considered the standard of practice. An oral temperature is a common measure but not the most reliable. A temporal thermometer scan has some limitations and is not the standard. The tympanic membrane sensor could be used as a second source for temperature assessment.

The nurse planning care for a patient with hypothermia would consider knowledge of similar exemplars including a. heat exhaustion. b. heat stroke. c. infection. d. prematurity.

ANS: D Prematurity, frost bite, environmental exposure, and brain injury are considered exemplars of hypothermia. Heat exhaustion is an exemplar of hyperthermia. Heat stroke is an exemplar of hyperthermia. Infection is an exemplar of hyperthermia.

A fever increases the cardiac output

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?

Remove the clothing.

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?

Evaporation

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?

Hypothalamus

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?

remittent

Temperature spikes and falls without a return to normal is considered

A compensatory response to fever

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:

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

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

Placing the newborn under a radiant warmer in the nursery

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?

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

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

Warming the newborn

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

Grow in conjunction with axillary hair follicles

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

Warm the environment.

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

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

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?

Core rewarming with warm fluids

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

Conduction

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?

Putting a hat on the infant's head

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

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

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?

The nurse admitting a patient to the emergency department on a very hot summer day would suspect hyperthermia when the patient demonstrates a. decreased respirations. b. low pulse rate. c. red, sweaty skin. d. slow capillary refill.

ANS: C With hyperthermia, vasodilatation occurs causing the skin to appear flushed and warm or hot to touch. There is an increased respiration rate with hyperthermia. The heart rate increases with hyperthermia. With hypothermia there is slow capillary refill.

Shivering

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:

38.5

An older adult with chills arrived to hospital. The nurse assesses the client's vital signs and determined the client has a fever. What would be the client's rectal temperature?

Administer the prescribed antipyretic and notify the primary health care provider

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:

Strategies to include in a community program for senior citizens related to dealing with cold winter temperatures would include a. avoiding hot beverages. b. shopping at an indoor mall. c. using a fan at low speed. d. walking slowly in the park.

ANS: B Shopping indoors where there is protection from the elements and temperature control is one strategy to avoid cold temperatures. Hot beverages can help an individual deal with cold weather. Avoiding breezes and air currents is recommended to conserve body temperature. Physical activity can increase body temperature, and if the senior is going to walk in the park, weather-appropriate (warm) clothing and a usual or brisk pace, not a slow pace, would be recommended.

During orientation to an emergency department, the nurse educator would be concerned if the new nurse listed which of the following as a risk factor for impaired thermoregulation? a. Impaired cognition b. Occupational exposure c. Physical agility d. Temperature extremes

ANS: C Physical agility is not a risk factor for impaired thermoregulation. The nurse educator would use this information to plan additional teaching to include medical conditions and gait disturbance as risk factors for hypothermia, because their bodies have a reduced ability to generate heat. Impaired cognition is a risk factor. Recreational or occupational exposure is a risk factor. Temperature extremes are risk factors for impaired thermoregulation.

A volunteer at the senior center asks the visiting nurse why the senior citizens always seem to be complaining about temperatures. The nurse's best response is that older people have a diminished ability to regulate body temperature because of a. active sweat glands. b. increased circulation. c. peripheral vasoconstriction. d. slower metabolic rates.

ANS: D Slower metabolic rates are one factor that reduces the ability of older adults to regulate temperature and be comfortable when there are any temperature changes. As the body ages, the sweat glands decrease in number and efficiency. Older adults have reduced circulation. The body conserves heat through peripheral vasoconstriction, and older adults have a decreased vasoconstrictive response, which impacts ability to respond to temperature changes.

The priority nursing intervention for a patient suspected to be hypothermic would be to a. assess vital signs. b. hydrate with intravenous (IV) fluids. c. provide a warm blanket. d. remove wet clothes.

ANS: D The first thing to do with a patient suspected to be hypothermic is to remove wet clothes, because heat loss is five times greater when clothing is wet. Assessing vital signs is important, but the wet clothes should be removed first. Hydration is very important with hyperthermia and the associated danger of dehydration, but there is not a similar risk with hypothermia. A warm blanket over wet clothes would not be an effective warming strategy.

Rewarm gradually

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

Removing excess clothing from the infant

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?