Thermoregulation Questions
Intermittent
A client has a fever spike that is combined with normal temperature levels. The client's body temperature returns to a normal body temperature at least once a day. Which type of fever can be assessed in the client? 1 Sustained 2 Relapsing 3 Remittent 4 Intermittent
Core rewarming with warm fluids
A client with hypothermia is brought to the emergency department. What treatment does the nurse anticipate? 1 Core rewarming with warm fluids 2 Ambulation to increase metabolism 3 Frequent oral temperature assessments 4 Gastric tube feedings to increase fluid volume
Estradiol
A woman reports weight gain and hot flashes. The client is also found to have low estrogen levels. Which drug may be prescribed to alleviate hot flashes? 1 Estradiol 2 Raloxifene 3 Clomiphene 4 Dinoprostone
Rewarm gradually
During the assessment of a preterm neonate the nurse determines that the infant is experiencing hypothermia. Which action should the nurse take? 1 Rewarm gradually 2 Notify the practitioner 3 Assess for hyperglycemia 4 Record skin temperature hourly
To treat hypocalcemic tetany
The nurse is caring for a client after thyroidectomy. The nurse notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed for which purpose? To treat thyroid storm To prevent cardiac irritability To treat hypocalcemic tetany To stimulate release of parathyroid hormone
Checking the child for frostbite The child must first be assessed for injuries caused by exposure and treated if necessary. A warm liquid may be offered after the child's physical status is assessed and it is determined that fluids may be ingested. Child Protective Services may be called after further assessment and the determination that neglect may be involved. Questions about the child's family dynamics may be asked after the status of the child is evaluated.
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? 1 Providing warm liquid to drink 2 Checking the child for frostbite 3 Calling Child Protective Services 4 Asking the child who helped him dress
Assessing respirations, keeping him warm, and identifying him Establishing a patent airway, diminishing cold stress, and identifying the newborn are the priorities. Application of eye prophylaxis and administration of vitamin K are often delayed to allow the parents to bond with the infant; a bath at this time will increase the risk of cold stress. Aspirating the oropharynx, rushing him to the nursery, and stimulating him frequently are measures appropriate for a compromised newborn; an 8/9 Apgar score is indicative of a healthy newborn. Weighing him, placing him in a crib, and waiting until the mother is ready to hold him are not the priority care for a newborn.
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? 1 Assessing respirations, keeping him warm, and identifying him 2 Applying an antibiotic to the eyes, administering vitamin K, and bathing him 3 Aspirating the oropharynx, rushing him to the nursery, and stimulating him often 4 Weighing him, placing him in a crib, and waiting until the mother is ready to hold him
Maintain a patent airway. Myxedema coma is a rare but serious disorder that results from persistently low thyroid production. Coma can be precipitated by acute illness, rapid withdrawal of thyroid medication, anesthesia and surgery, hypothermia, and the use of sedatives and opioid analgesics. In myxedema coma, the initial nursing action is to maintain a patent airway. Oxygen needs to be administered, followed by fluid replacement, keeping the client warm, monitoring vital signs, and administering thyroid hormones by the intravenous route.
A client is admitted to an emergency department, and a diagnosis of myxedema coma is made. Which action would the nurse prepare to carry out initially? Warm the client. Maintain a patent airway. Administer thyroid hormone. Administer fluid replacement.
Assess the sides and back of the client's neck for evidence of bleeding. In a back-lying (supine) position, blood will flow with gravity down the sides of the neck and not be seen. Positioning two pillows behind the client's head flexes the neck excessively; this increases tension on the suture line and may inhibit the passage of gases through the oral, pharyngeal, and tracheal areas. A small pillow behind the head keeps the head and neck in functional alignment and limits tension on the suture line. Although tetany resulting from hypocalcemia may be a complication of this surgery, tetany will not occur during the first 8 hours after surgery. Although deep breathing should be encouraged, coughing should not be encouraged during the first 24 to 48 hours, to limit stress on the suture line.
A client is admitted to the hospital with a diagnosis of cancer of the thyroid gland, and a thyroidectomy is performed. What should the nurse do during the first six to eight hours after surgery? 1 Place two pillows behind the client's head. 2 Monitor for the complication of tetany resulting from hypocalcemia. 3 Assess the sides and back of the client's neck for evidence of bleeding. 4 Encourage the client to perform deep-breathing and coughing exercises.
Increased heart rate Prolonged exposure to the sun or a high environmental temperature overwhelms the body's heat-loss mechanisms. These conditions cause heat stroke, which manifests as giddiness, excessive thirst, and nausea. An increased heart rate (HR) characterizes a heat stroke. A low blood pressure (BP), increased respiratory rate, and increased circulatory and tissue damage are not indicators of heat stroke.
A client with a history of hypothyroidism reports giddiness, excessive thirst, and nausea. Which parameter assessed by the nurse confirms the diagnosis as heat stroke? 1 Increased heart rate 2 Increased blood pressure 3 Decreased respiratory rate 4 Increased circulatory damage
Administer methimazole with food. Assess the client for unexplained bruising or bleeding. Instruct the client to report side and adverse effects such as sore throat, fever, or headaches. Common side effects of methimazole include nausea, vomiting, and diarrhea. To address these side effects, this medication needs to be taken with food. Because of the increase in metabolism that occurs in hyperthyroidism, the client needs to consume a high-calorie diet. Antithyroid medications can cause agranulocytosis with leukopenia and thrombocytopenia. Sore throat, fever, headache, or bleeding may indicate agranulocytosis, and the primary health care provider needs to be notified immediately. Methimazole is not radioactive and would not be stopped abruptly, due to the risk of thyroid storm.
A client with hyperthyroidism has been given methimazole. Which nursing considerations are associated with this medication? Select all that apply. Administer methimazole with food. Place the client on a low-calorie, low-protein diet. Assess the client for unexplained bruising or bleeding. Instruct the client to report side and adverse effects such as sore throat, fever, or headaches. Use special radioactive precautions when handling the client's urine for the first 24 hours following initial administration.
Calcium
A client with medullary carcinoma of the thyroid has an excess function of the C cells of the thyroid gland. When reviewing the most recent laboratory results, the nurse would expect which electrolyte abnormality? Sodium Calcium Potassium Magnesium
Dehydration A client's temperature may be elevated to 100.4° F (38° C) during the first 24 hours after delivery because of dehydration resulting from the exertion and stress of labor. Mastitis usually develops after breastfeeding is established and the milk supply is present. Puerperal infection usually begins with a fever of 100.4° F (38 °C) or higher on 2 successive days, excluding the first 24 hours after delivery. Urinary tract infection usually becomes evident later in the postpartum period.
A client's temperature is 100.4° F (38° C) 12 hours after a spontaneous vaginal birth. What does the nurse suspect is the cause of the increased temperature? 1 Mastitis 2 Dehydration 3 Puerperal infection 4 Urinary tract infection
Report the client's condition to the primary healthcare provider A client who underwent a cervical biopsy may have a body temperature of 100° F, increased abdominal pain, and foul-smelling drainage due to infection. The nurse should report these findings regarding the client's condition to the primary healthcare provider to prevent sepsis. Analgesics may reduce the pain in the client, but not the other symptoms. Placing the client in the lithotomy position will not provide adequate comfort. The client should not douche the genital area for about two weeks after a cervical biopsy.
A nurse is caring for a client who underwent a cervical biopsy. The nurse finds that the client has a body temperature of 100° F, increased abdominal pain, and increased drainage that is foul-smelling. Which action is priority? 1 Administer analgesics to the client 2 Place the client in the lithotomy position 3 Ask the client to douche the perineal area 4 Report the client's condition to the primary healthcare provider
3 Weight gain 4 Cold intolerance
A nurse is caring for a client with an underactive thyroid gland. Which responses should the nurse expect the client to exhibit as a result of decreased levels of triiodothyronine (T 3) and thyroxine (T 4)? Select all that apply. 1 Irritability 2 Tachycardia 3 Weight gain 4 Cold intolerance 5 Profuse diaphoresis
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? 1 Bottle feeding immediately after birth 2 Dressing the newborn in a shirt and gown immediately 3 Bathing the newborn in warm water as soon as possible 4 Putting the naked newborn on the mother's skin and covering the infant with a blanket
Metabolism of brown fat Metabolism of brown fat releases energy and increases heat production in the newborn. Fatty acids are by-products of the breakdown of brown fat. Shivering is the mechanism of heat production for an adult, not for a newborn. Increased muscular activity will not be successful unless there is an abundance of brown fat.
A nursing instructor provides education for the students on thermoregulation in the nursery. What do the students determine produces heat in the healthy full-term neonate? 1 Shivering when chilled 2 Metabolism of brown fat 3 Oxidization of fatty acids 4 Increased muscular activity
Preventing shivering
A parent tells the nurse in the emergency department, "My 3-year-old has had a fever for several days and has been vomiting." After prescribed measures to reduce the fever have been instituted, what nursing action is most important? 1 Preventing shivering 2 Restricting oral fluids 3 Measuring output hourly 4 Taking vital signs hourly
Put a hat on the infant's head to prevent hypothermia
A preterm neonate is receiving oxygen by way of an overhead hood. Which nursing interventions should the nurse implement to protect the infant under the oxygen hood? 1 Offer fluid every 15 minutes to prevent dehydration 2 Put a hat on the infant's head to prevent hypothermia 3 Keep the oxygen concentration consistent to limit respiratory distress 4 Remove the infant from the hood every 15 minutes to provide stimulation
Conduction Conduction is the conveyance of energy such as heat, cold, or sound by direct contact. Direct contact is not necessary to convey heat by radiation. Insulation refers to retention of heat, not its transfer. Convection is the transfer of heat by air circulation (e.g., by fans or open windows).
A primary healthcare provider prescribes the application of a warm soak to an intravenous (IV) site that has infiltrated. Which principle does the nurse determine is in operation when the application of local heat transfers temperature to the body? 1 Radiation 2 Insulation 3 Convection 4 Conduction
A fever increases the cardiac output. Temperatures of 102° F (38.9° C) or greater lead to an increased metabolism and cardiac workload. Although diaphoresis is related to an elevated temperature, it is not the reason for notifying the healthcare provider. An elevated temperature is not an early sign of cerebral edema. Open heart surgery is not associated with cerebral edema. Fever is unrelated to hemorrhage; in hemorrhage with shock, the temperature decreases.
After surgery for insertion of a coronary artery bypass graft (CABG), a client develops a temperature of 102° F (38.9° C). Which priority concern related to elevated temperatures does a nurse consider when notifying the healthcare provider about the client's temperature? 1 A fever may lead to diaphoresis. 2 A fever increases the cardiac output. 3 An increased temperature indicates cerebral edema. 4 An increased temperature may be a sign of hemorrhage.
Evaporation Evaporative heat loss is a result of the conversion of moisture into vapor, which is avoided when the newborn is dried. Radiation is the loss of heat to colder solid surfaces that are not in direct contact. Convective heat loss is a result of contact of the exposed skin with cooler surrounding air currents. Conductive heat loss is a result of direct skin contact with a cold solid object.
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? 1 Radiation 2 Convection 3 Conduction 4 Evaporation
1 Flexed fetal position 3 Brown fat metabolism 4 Peripheral vasoconstriction Full-term neonates maintain a flexed fetal position, which conserves heat. Deposition of brown fat begins at 28 weeks' gestation and continues for the rest of the pregnancy; when the newborn's body becomes cool, the sympathetic nervous system stimulates the breakdown of brown fat, which releases heat as a by-product. Peripheral vasoconstriction helps conserve heat by keeping the central core warm and preventing heat from dissipating. Insulin is not stored in the liver and is not involved with maintenance of neonatal body temperature. The sympathetic, not parasympathetic, nervous system is involved in thermoregulation.
Neonates have difficulty maintaining their body temperature; however, their bodies have several mechanisms to help them do so. Which ones should a nurse remember when caring for the newborn? Select all that apply. 1 Flexed fetal position 2 Hepatic insulin stores 3 Brown fat metabolism 4 Peripheral vasoconstriction 5 Parasympathetic nervous system
Fever An adverse effect of propylthiouracil is agranulocytosis. The client needs to be informed of the early signs of this side and adverse effect, which include fever and sore throat. Drowsiness is an occasional side effect of the medication. Dry mouth and increased urination are unrelated to this medication.
Propylthiouracil is prescribed for a client with hyperthyroidism. The nurse provides instructions to the client regarding the medication and informs the client to notify the primary health care provider (PHCP) if which sign or symptom occurs? Fever Dry mouth Drowsiness Increased urination
Hypothalamus The hypothalamus connects with the autonomic area for vasoconstriction, vasodilation, and perspiration and with the somatic centers for shivering; therefore, it is an important area for regulating body temperature. The thalamus receives all sensory stimuli, except taste, for transmission to the cerebral cortex; it is also involved with emotions and instinctive activities. The temporal lobe is concerned with auditory stimuli; it also may be involved with the sense of smell. The globus pallidus is part of the basal ganglia, required for specific body movements.
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 which structure? 1 Thalamus 2 Hypothalamus 3 Temporal lobe 4 Globus pallidus
Moderate hypothermia The nurse would treat the client for moderate hypothermia because increased incoherence and possible stupor are symptoms of the condition. Frostnip is a type of superficial cold injury that may produce pain, numbness, and pallor of the affected area but is easily relieved by applying warmth. This condition does not cause tissue damage. Mild hypothermia is characterized by shivering and decreased muscle coordination. Bradycardia, along with severe hypotension and decreased respiratory rate, are the symptoms of severe hypothermia.
The client presents to the emergency department with increasing incoherence and periods of stupor. According to the EMS, the client was found wandering outside in the cold without a coat. Which condition would the nurse consider to be responsible for the client's signs and symptoms? 1 Frostnip 2 Mild hypothermia 3 Severe hypothermia 4 Moderate hypothermia
Rectal Although the oral route is the most common route for monitoring body temperature, clients who are unconscious should have their temperatures monitored rectally. Skin temperature may be impaired due to diaphoresis; this measurement may not reliable. The axilla temperature may underestimate the core temperature.
The nurse cares for an unconscious client who underwent head surgery. Which site would be best used to monitor body temperature? 1 Skin 2 Oral 3 Axilla 4 Rectal
Body temperature of 81.2°F Severe hypothermia such as body temperature of 81.2° F must be immediately corrected by infusing warm fluids and blood. This helps to prevent hypothermia-related complications. A Glasgow Coma score of 10 needs medium priority since it does indicate immediate danger to the client. Oxygen saturation of 90 percent indicates a manageable status. Presence of carotid pulse with blood pressure of 80 mm Hg is acceptable.
The nurse is assessing a client with hemorrhagic stroke due to a motor bike accident. Which condition of the client requires immediate attention? 1 Glasgow Coma score of 10 2 Body temperature of 81.2°F 3 Oxygen saturation of 90 percent 4 Presence of carotid pulse with blood pressure of 80 mm Hg
"I need to place my hands behind my neck when I have to cough or change positions."
The nurse is caring for a client who is scheduled to have a thyroidectomy and provides instructions to the client about the surgical procedure. Which client statement indicates an understanding of the nurse's instructions? "I expect to experience some tingling of my toes, fingers, and lips after surgery." "I will definitely have to continue taking antithyroid medications after this surgery." "I need to place my hands behind my neck when I have to cough or change positions." "I need to turn my head and neck front, back, and laterally every hour for the first 12 hours after surgery."
Periorbital edema Coarse, brittle hair Slow or slurred speech Abdominal distention
The nurse is caring for a client with a new diagnosis of hypothyroidism. Which clinical manifestations might the nurse expect to note on examination of this client? Select all that apply. Irritability Periorbital edema Coarse, brittle hair Slow or slurred speech Abdominal distention Soft, silky, thinning hair
Tingling around the mouth
The nurse is monitoring a client for signs of hypocalcemia after thyroidectomy. Which sign or symptom, if noted in the client, would most likely indicate the presence of hypocalcemia? Bradycardia Flaccid paralysis Tingling around the mouth Absence of Chvostek's sign
Has a limited supply of brown fat available to provide heat
The nurse must continually assess a preterm infant's temperature and provide appropriate nursing care because, unlike the full-term infant, the preterm infant has what limitation? 1 Cannot use shivering to produce heat 2 Cannot break down glycogen to glucose 3 Has a limited supply of brown fat available to provide heat 4 Has a limited amount of pituitary hormones with which to control internal heat
"It suppresses thyroid hormone."
The nurse provides education to the client with hyperthyroidism about potassium iodide before medication administration. The client is scheduled for a subtotal thyroidectomy. Which response by the client indicates understanding? "It replaces thyroid hormone." "It prevents iodine absorption." "It increases thyroid hormone." "It suppresses thyroid hormone."
Instruct the client about thyroid replacement therapy. Encourage the client to consume fluids and high-fiber foods in the diet. Instruct the client to contact the primary health care provider (PHCP) if episodes of chest pain occur.
The nurse would include which interventions in the plan of care for a client with hypothyroidism? Select all that apply. Provide a cool environment for the client. Instruct the client to consume a high-fat diet. Instruct the client about thyroid replacement therapy. Encourage the client to consume fluids and high-fiber foods in the diet. Inform the client that iodine preparations will be prescribed to treat the disorder. Instruct the client to contact the primary health care provider (PHCP) if episodes of chest pain occur.
"I will apply an ice pack to the client." "I will cover the client with dark clothes." "I will instruct the client to lie in the fetal position." Applying an ice pack will increase conductive heat loss, which results in minimizing heat radiation. Wearing dark clothes and lying in the fetal position will minimize heat radiation. Removing extra clothes will increase heat radiation. Wearing sparsely woven clothes will enhance heat radiation
The registered nurse is teaching a nursing student about ways to minimize heat radiation. Which statements made by the nursing student indicate effective learning? Select all that apply. 1 "I will apply an ice pack to the client." 2 "I will cover the client with dark clothes." 3 "I will instruct the client to remove extra clothes." 4 "I will instruct the client to lie in the fetal position." 5 "I will advise the client to wear sparsely woven clothes."
3 88° F (31.1° C) 4 92° F (33.3° C) Moderate hypothermia is a body temperature between 86°F and 93.2°F (30° C to 34° C). Therefore clients with body temperatures between 88°F and 92°F (31.1° C to 33.3° C) have moderate hypothermia. Mild hypothermia is a body temperature between 93.2°F and 96.8°F (34° C to 36° C). Therefore clients with body temperatures of 96°F (35.6° C) have mild hypothermia. Body temperature below 86°F (30° C) indicates severe hypothermia.
Which client body temperatures are indicative of moderate hypothermia? Select all that apply. 1 80° F (26.7° C) 2 84° F (28.9° C) 3 88° F (31.1° C) 4 92° F (33.3° C) 5 96° F (35.6° C)
Body temperature of 102° F with vaginal discharge 48 hours after cervical biopsy The client with cervical biopsy should immediately report to the primary healthcare provider if experiencing a body temperature of 102° F with vaginal discharge. This is because fever and vaginal discharge that develops 48 hours after cervical biopsy may be the signs of infection related to the procedure. The client should take pain relievers for pelvic pain after colposcopy. Light vaginal bleeding for 1 to 2 days following hysterosalpingogram is common. If the amount of bleeding increases or extends beyond 2 days, the healthcare provider should be notified. Light rectal bleeding for a few days is common after prostate biopsy.
Which condition should be reported immediately to the primary healthcare provider? 1 Pelvic pain immediately after colposcopy 2 Light vaginal bleeding for 1 to 2 days following a hysterosalpingogram 3 Rectal bleeding for 2 days after prostate biopsy 4 Body temperature of 102° F with vaginal discharge 48 hours after cervical biopsy
Increased expired carbon dioxide The first sign of malignant hyperthermia [1] [2] is increased expired carbon dioxide, caused by an abnormal and continuous contraction of the skeletal muscles. Due to metabolic changes in the skeletal muscles, there may be abnormal rapid breathing (tachypnea) and abnormal rapid heart rate (tachycardia), but it is not considered the first sign of malignant hyperthermia. Increased body temperature is often late to appear during malignant hyperthermia.
Which is the first sign that would help the nurse in diagnosing malignant hyperthermia in a client? 1 Abnormal rapid heart rate 2 Abnormal rapid breathing 3 Increased body temperature 4 Increased expired carbon dioxide
Keep the infant in a double-walled incubator for a few hours. The normal body temperature of a term infant is in the range of 97.7° F to 99.5° F (36.5° C to 37.5° C). A body temperature of 95.5° F (35.3° C) indicates hypothermia. Double-walled incubators can effectively maintain normal body temperature by reducing heat loss. Removing the infant's clothes can further increase the risk of hypothermia. The nurse should apply a fabric-insulated or wool cap to the infant to prevent further heat loss. Wiping the infant's body with water exacerbates the risk of hypothermia.
While assessing a term infant a few hours after birth, the nurse finds a body temperature of 95.5° F (35.3° C). What does the nurse do in this situation? 1 Avoid applying a fabric-insulated or wool cap. 2 Remove clothing and expose the infant to room air. 3 Keep the infant in a double-walled incubator for a few hours. 4 Instruct the parents to wipe the neonate's body with warm water.
Axilla
A client was admitted to a surgical unit in an unconscious state due to head trauma. Which site would be most appropriate to obtain the client's temperature? 1 Oral 2 Axilla 3 Temporal artery 4 Tympanic membrane
Amenorrhea
A 33-year-old client is admitted to the hospital with a tentative diagnosis of Graves' disease. Which symptom related to the menstrual cycle would the client be most likely to report during the initial assessment? Amenorrhea Menorrhagia Metrorrhagia Dysmenorrhea
The client is suffering from severe hypothermia. The nurse as a nursing priority should avoid active external rewarming for the client with heating devices in case of severe hypothermia. Extreme heating is contraindicated in this kind of client due to rapid vasodilation. Frostnip is a type of superficial cold injury that can be treated with warmth without causing any tissue damage. In case of frostbite, the nurse should not use dry heat or massage the frostbitten area of the client's body. Moderate hypothermia can be cured by both active external and core rewarming methods.
As a nursing priority, the nurse avoids active external rewarming with heating devices because it is contraindicated due to rapid vasodilation. From which condition is the client suffering? 1 The client is suffering from frostnip. 2 The client is suffering from frostbite. 3 The client is suffering from severe hypothermia. 4 The client is suffering from moderate hypothermia
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 which structure? 1 Thalamus 2 Hypothalamus 3 Temporal lobe 4 Globus pallidus
Skin Axilla The skin and axilla are safe and inexpensive sites of the body for temperature measurement. The oral route is an easily accessible site for temperature measurement but it may not be the safest route because of the exposure to body fluids. The rectal route may not be easily accessible and safe because a measurement via this route may increase the risk of body fluid exposure. The tympanic membrane is an easily accessible site for temperature measurement but care should be taken when used in neonates, infants, and children.
Which sites would be safe and inexpensive for temperature measurement? Select all that apply. 1 Skin 2 Oral 3 Axilla 4 Rectal 5 Tympanic membrane
Relapsing
While assessing a client with chills and fever, the nurse observes that the febrile episodes are followed by normal temperatures and that the episodes are longer than 24 hours. Which fever pattern does the nurse anticipate? 1 Relapsing 2 Sustained 3 Remittent 4 Intermittent