Unit 2 - PrepU Thermoregulation

b. Withhold the client's next dose of fluphenazine, call the physician, and monitor the client's vital signs

A client with chronic schizophrenia has received 10 mg of fluphenazine PO QID. Now the client has a temperature of 102 deg F (38.9 deg C), a heart rate of 120 beats/minute, a respiratory rate of 20 breaths/minute, and a blood pressure of 210/140 mmHg. Because the client is also confused and incontinent, the nurse suspects neuroleptic malignant syndrome. What steps should the nurse take? a. Give the client his next dose of fluphenazine, call the physician, and monitor the client's vital signs b. Withhold the client's next dose of fluphenazine, call the physician, and monitor the client's vital signs c. Give the client his next dose of fluphenazine and restrict him to his room to decrease stimulation d. Withhold the client's next dose of fluphenazine, administer an antipyretic agent, and increase the client's fluid intake.

b. "The least costly method to determine ovulation patterns is to record the basal body temperature for at least 4 months."

A female client comes to the clinic and asks the nurse what would be the most cost effective method for her to determine her ovulation patterns. What is the BEST response by the nurse? a. "The least costly method would be a surgical procedure to determine if your fallopian tubes are blocked." b. "The least costly method to determine ovulation patterns is to record the basal body temperature for at least 4 months." c. "The least costly method would be to purchase a commercial kit from the store to assess the upsurge of LH that occurs just after ovulation." d. "The least costly method would be to purchase an at-home testing kit for sperm motility."

a. Attach a cardiac monitor

A homeless client presents to the ED. Upon assessment, the client is experiencing hypothermia. The nurse will plan to complete which priority intervention during the rewarming process? a. Attach a cardiac monitor b. Insert a Foley urinary catheter c. Assist with endotracheal intubation d. Administer inotropic drugs

c. "It is because of the immature ability to regulate temperature in general."

A nurse is assessing a newborn at the health care facility when the mother of the child asks the nurse why the body temperature of her baby is unstable. Which response by the nurse would be MOST appropriate? a. "The baby is showing how it is adapting to the environmental temperature." b. "It is common for newborns to have body temperatures less than 36.4 deg C (97.6 deg F)." c. "It is because of the immature ability to regulate temperature in general." d. "It is because of the closely woven, dark fabric wrapped around the baby."

a. Peeling hands and feet and fever

A nurse is caring for a child with Kawasaki disease. Which assessment finding would the nurse expect to see? a. Peeling hands and feet and fever b. Decreased heart rate and impalpable pulse c. Irritability and dry mucous membranes d. Low blood pressure and decreased heart rate

a. "He seems listless and slightly warm."

A nurse is taking the history of a 4-year-old boy who will undergo a cardiac catheterization. Which statement by his mother may necessitate rescheduling of the procedure? a. "He seems listless and slightly warm." b. "He is allergic to iodine and shellfish." c. "He is very scared and nervous about the procedure." d. "He is not taking any medications."

b. rest in an air-conditioned room

A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to a. take a hot bath b. rest in an air-conditioned room c. increase the dose of muscle relaxants d. avoid naps during the day

d. newly born preterm infant

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? a. term infant with the diagnosis of Rh incompatibility b. two-day-old infant postdates at birth c. one-day-old infant of a diabetic mother d. newly born preterm infant

d. Hyperpyrexia, severe hypertension, and diaphoresis

A nursing assessment of a client who has been diagnosed with neuroleptic malignant syndrome (NMS) would MOST likely reveal which signs? a. Chest pain, tachycardia, and cardiac dysrhythmias b. Respiratory distress, cyanosis, and pallor c. Nausea, vomiting, diarrhea, and gastric pain d. Hyperpyrexia, severe hypertension, and diaphoresis

a. Dantrolene sodium (Dantrium)

A patient is having surgery to repair a ruptured Achilles tendon. The patient develops severe muscle contractions and hyperthermia. Which medications will be administered? a. Dantrolene sodium (Dantrium) b. Baclofen (Lioresal) c. Carisoprodol (Soma) d. Cyclobenzaprine (Flexeril)

d. Administer an analgesic as ordered

A patient with frostbite to both lower extremities from exposure to the elements is preparing to have rewarming of the extremities. What intervention should the nurse provide prior to the procedure? a. Massage the extremities b. Elevate the legs c. Apply a heat lamp d. Administer an analgesic as ordered

b. body temperature of 102.8 deg F (39.3 deg C)

A toddler hospitalized with nephrotic syndrome has marked dependent edema and hypoalbuminemia. His urine is frothy. When assessing the child's vital signs, the nurse should report which finding to the primary care provider? a. blood pressure of 80/45 mmHg b. body temperature of 102.8 deg F (39.3 deg C) c. pulse rate of 85 bpm d. respiratory rate of 28 breaths/minute

d. Continue to monitor the woman's temperature every 4 hours; this finding is normal

A woman gave birth vaginally approximately 12 hours ago, and her temperature is now 100 deg F (37.8 deg C). Which action would be MOST appropriate? a. Notify the health care provider about this elevation; this finding reflects infection b. Obtain a urine culture; the woman most likely has a urinary tract infection c. Inspect the perineum for hematoma formation d. Continue to monitor the woman's temperature every 4 hours; this finding is normal

b. applying a blanket

The nurse assesses that a client is shivering. Which intervention is MOST appropriate to prevent further stress on the body? a. applying a cooling blanket b. applying a blanket c. raising the room temperature d. providing warm fluids

c. Dress the newborn in ways to preserve warmth d. Take the newborn's temperature often e. Supply oxygen for the newborn, if needed

The nurse in the NICU is caring for preterm newborns. Which guidelines are recommended for care of these newborns? Select all that apply. a. Handle the newborn as much as possible b. Give the newborn a warm bath immediately c. Dress the newborn in ways to preserve warmth d. Take the newborn's temperature often e. Supply oxygen for the newborn, if needed f. Discourage contact with parents to maintain asepsis.

d. The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.

The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly? a. The nurse uses a safety pin to attach the pad to the bedding. b. The nurse covers the heating pad with a heavy blanket. c. The nurse places the heating pad under the client's neck. d. The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.

b. "The child's sympathetic nervous system was damaged in the accident."

The nurse is caring for a child who sustained a spinal cord injury in a motor vehicle accident. The child's body temperature fluctuates markedly, and the parents question why this is occurring. What is the most accurate response for the nurse to give to the parents? a. "The child has probably developed pneumonia and needs antibiotics b. "The child's sympathetic nervous system was damaged in the accident." c. "Urinary tract infections are common in children with spinal cord injuries." d. "It is hard to obtain accurate temperatures in children with spinal cord injuries.

b. temperature 101.8 deg F (38.8 deg C), BP 140/86 mmHg, HR 94 bpm, RR 24/min

The nurse is caring for a client who had an open cholecystectomy 24 hours ago. The client's vital signs have been stable over the last 24 hours, with most recent temperature 98.6 deg F (37 deg C), blood pressure (BP) 118/76 mmHg, respiratory rate (RR) 16/min, and heart rate (HR) 78 bpm, but are now changing. Which set of vital signs indicates that the nurse should contact the health care provider (HCP)? a. temperature 100.7 deg F (38.2 deg C), BP 118/68 mmHg, HR 84 bpm, RR 20/min b. temperature 101.8 deg F (38.8 deg C), BP 140/86 mmHg, HR 94 bpm, RR 24/min c. temperature 99.5 deg F (37.5 deg C), BP 126/80 mmHg, HR 58 bpm, RR 16/min d. temperature 97.5 deg F (36.4 deg C), BP 98/64 mmHg, HR 98 bpm, RR 18/min

b. Convection c. Radiation d. Conduction e. Evaporation

The nurse is caring for a neonate at risk for lower body temperature. Which processes should the nurse address? Select all that apply. a. Dilation b. Convection c. Radiation d. Conduction e. Evaporation

b. "The largest organ of the body helps regulate body temperature."

The nurse is reviewing the integumentary system during a presentation to a group of nurses. Which statement made by the nurse is the MOST accurate regarding the integumentary system? a. "The sebaceous glands are fully functional in the infant." b. "The largest organ of the body helps regulate body temperature." c. "The integumentary system is not in place until after the child is born and then takes many years to mature." d. "One role of the integumentary system is to distribute oxygen to the body cells."

d. "A late preterm newborn may have more clinical problems compared with full-term newborns."

The nurse is teaching nursing students about the risks that late preterm infants may experience. The nurse feels confident that learning has taken place when the students make which statement? a. "Late preterm infant complications are considered minor compared to the preterm newborn." b. "The late preterm infant is more mature and able to cope as well as a full-term infant." c. "Late preterm newborns have fewer clinical problems leading to shorter hospital stays." d. "A late preterm newborn may have more clinical problems compared with full-term newborns."

a. Anticipate IV administration of dantrolene

The perioperative 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? a. Anticipate IV administration of dantrolene b. Initiate resuscitation c. Prepare to adiminister acetylcysteine IV d. Administer naloxone IV as per facility protocol

True

True or False: During measurement of a rectal temperature ,the thermometer probe should be inserted about 1.5 inches (3.8 cm) in an adult and 0.5 inches (1.3 cm) in an infant.

b. Cover the client with warmed blankets

Vital Signs at 0830: Pulse 80, Respirations 16, BP 90/60, Temperature 99.5 (37.5) Vital Signs at 2230: Pulse 90, Respirations 20, BP 100/80, Temperature 97 (36.1) A nurse is assessing a client when she returns from same-day surgery for a dilatation and curettage. The nurse checks preoperative vital signs at 0830 to compare them with the current vital signs at 2230 (see above). What should the nurse do FIRST? a. Call the health care provider (HCP) for pain medication. b. Cover the client with warmed blankets. c. Administer oxygen at 4 L/min. d. Increase the IV fluid rate.

c. Verbally report the finding immediately to the client's physician

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 client's temperature is 39.4 deg C. What should be the nurse's priority action? a. Verbally report the finding to the charge nurse at the change of shift b. Inform the unlicensed assistant personnel to document the finding c. Verbally report the finding immediately to the client's physician d. Reassess the client's temperature in 2 hours and chart this data

d. A respiratory or ear infection is usually present

A nurse is providing health teaching to the parents of a 2-year-old child who has been diagnosed with benign febrile seizures. What is the most important information for the nurse to give the parents about this disorder? a. It will result in a developmental delay for the child b. This diagnosis often progresses to one of epilepsy c. The seizures will continue throughout the child's life d. A respiratory or ear infection is usually present

b. Malignant hyperthermia

An operating room nurse is assisting the anesthesiologist in the preparation of an intravenous dose of dantrolene. What emergent issue MOST likely prompted the need to give the patient dantrolene? a. Cerebrovascular accident b. Malignant hyperthermia c. Myocardial ischemia d. Uncontrolled hypertension

c. "My mother said she always used a glass thermometer when I was a kid and it was very accurate. Maybe that would be better."

The father of a toddler tells the nurse tat his child had a fever the previous night. During the assessment, which statement by the father indicates further discussion is necessary regarding temperature measurement? a. "I used one of those thermometers that goes in the ear, but I don't think it was accurate." b. "We have an electronic oral thermometer. It seemed to match our child's symptoms of fever better." c. "My mother said she always used a glass thermometer when I was a kid and it was very accurate. Maybe that would be better." d. "I know rectal temperature is pretty accurate but I didn't see that it was necessary to cause the discomfort of that route."

a. Dantrolene sodium (Dantrium)

What medication should the nurse prepare to administer in the event the patient has malignant hyperthermia? a. Dantrolene sodium (Dantrium) b. Fentanyl citrate (Sublimaze) c. Narcan d. Thiopental sodium (Pentobarbital)

d. body temperature

When caring for a client who is post-intracranial surgery what is the most important parameter to monitor? a. extreme thirst b. intake and output c. nutritional status d. body temperature

c. Penicillin to prevent acute glomerulonephritis

When the physician looks in a child's mouth during a sick-visit exam, the mother exclaims: "Her tongue is bright red! It was not like that yesterday." The physician would MOST likely order which medication based on the probable diagnosis of scarlet fever? a. Steroids to decrease the inflammation b. Acetaminophen to decrease the throat pain c. Penicillin to prevent acute glomerulonephritis d. Erythromycin to prevent the spread to siblings

a. Tachycardia (heart rate > 150 bpm)

Which clinical manifestation is often the earliest sign of malignant hyperthermia? a. Tachycardia (heart rate > 150 bpm) b. Hypotension c. Elevated temperature d. Oliguria

c. Bathe the baby under a radiant warmer

Which intervention would be the BEST way for the nurse to prevent heat loss in a newborn while bathing? a. Limit the bathing time to 5 minutes b. Bathe the baby in water between 90 and 93 degrees. c. Bathe the baby under a radiant warmer d. Postpone breastfeeding until after the initial bath.

a. ruptured membranes

A 24-year-old primigravid client in active labor requests use of the jet hydrotherapy tub to aid in pain relief. The nurse understands that which condition is a contraindication to hydrotherapy? a. ruptured membranes b. multifetal gestation c. diabetes mellitus d. hypotonic labor patterns

a. Difficulty speaking b. Drooling c. Sitting with neck extended d. Frightened appearance

A 5-year-old child is brought to the clinic by his father because the child developed a high fever over the past 2 to 3 hours. The nurse suspects epiglottitis based on which signs and symptoms? Select all that apply. a. Difficulty speaking b. Drooling c. Sitting with neck extended d. Frightened appearance e. Cough

c. keep the room temperature low and bedclothes to a minimum

A child is admitted to the hospital with a febrile seizure. The nurse should: a. keep the child supine b. place the child in isolation c. keep the room temperature low and bedclothes to a minimum d. place a padded tongue blade at the bedside

a. the male preterm infant born by cesarean birth with cold stress

A nurse working in the newborn observational unit is assigned four newborns closely being monitored. Which newborn is an greatest risk of developing respiratory distress syndrome? a. the male preterm infant born by cesarean birth with cold stress b. the preterm female infant born vaginally whose mother has asthma c. the term male infant born vaginally with a positive Babinski reflex d. the term female infant whose mother has hypertension

a. malignant hyperthermia

During a procedure, a client's temperature begins to rise rapidly. This is likely the result of which complication? a. malignant hyperthermia b. hypothermia c. infection d. fluid volume excess

c. open body wounds

Hypothermia may occur as a result of a. the infusion of warm fluids b. increased muscle activity c. open body wounds d. being young

b. Apply ice to the affected area

The camp nurse is caring for a child who was bitten on the leg by a dangerous spider. The child is being taken to a care provider. What is the MOST appropriate action for the nurse to do with this child? a. Administer pain medication b. Apply ice to the affected area c. Splint the leg d. Briskly scrub the site

b. Hunger c. Blood pressure d. Reproduction

The hypothalamus is responsible for regulating which functions? Select all that apply. a. Muscle contraction b. Hunger c. Blood pressure d. Reproduction e. Fine motor movements

b. Remove the thermometer and assess the blood pressure and heart rate.

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? a. Leave the thermometer in and notify the physician b. Remove the thermometer and assess the blood pressure and heart rate c. Remove the thermometer and assess the temperature via another method. d. Call for assistance and anticipate the need for CPR.

a. Chills

When an infection is bloodborne, the manifestations include which symptom? a. Chills b. Bradycardia c. Hypothermia d. Hyperactivity

a. Reassess the client's temperature in 1 hour.

A client admitted with a wound infection has a temperature of 102.1 deg F. The nurse administers ordered acetaminophen. How does the nurse plan to reassess the effectiveness of the medication? a. Reassess the client's temperature in 1 hour. b. Reassess the client's white blood cell count in 1 hour. c. Reassess the client's respiratory rate in 1 hour. d. Reassess the would exudate in 1 hour.

a. Scarlet fever

A 6-year-old child is brought to the clinic by his parents. The parents state, "He had a sore throat fora couple of days and now his temperature is over 102 deg F (38.9 deg C). He has this rash on his face and chest that looks like sunburn but feels really rough." What would the nurse suspect? a. Scarlet fever b. Community-acquired methicillin-resisitant Staphylococcus aureas (CAMRSA) c. Diphtheria d. Pertussis

c. Wear gloves when obtaining food from the refrigerator

In order to prevent recurrent vasospastic episodes with Raynaud's phenomenon, what should the nurse instruct the client to do? a. Keep the hands and feet elevated as much as possible b. Use a vibrating massage device on the hands c. Wear gloves when obtaining food from the refrigerator d. Increase coffee intake to 2 cups per day

b. Rectum

A nurse is caring for an adult with fever. The nurse determines that which site is most ideal for obtaining the client's core body temperature? a. Ear b. Rectum c. Axilla d. Mouth

d. Morphine

After teaching a class about agents commonly associated with the development of malignant hyperthermia, the instructor determines that additional teaching is needed when the students identify which drug is a possible cause? a. Halothane b. Succinylcholine c. Epinephrine d. Morphine

d. Move the adolescent to a cool environment

An adolescent is on the football team and practices in the morning and afternoon before school starts for the year. The temperature on the field has been high. The school nurse has been called to the practice field because the adolescent is now reporting that he has muscle cramps, nausea, and dizziness. Which action should the school nurse do FIRST? a. Administer cold water with ice cubes b. Take the adolescent's temperature c. Have the adolescent go to the swimming pool d. Move the adolescent to a cool environment

a. Carefully test the temperature of bath water. c. Avoid hot water bottles and heating pads. d. Inspect the skin daily for injury or pressure points. e. Wear warm clothing when outside in cold weather.

Which information should the nurse include in the discharge plan for a client with multiple sclerosis who has an impaired peripheral sensation? Select all that apply. a. Carefully test the temperature of bath water. b. Avoid kitchen activities because of the risk of injury. c. Avoid hot water bottles and heating pads. d. Inspect the skin daily for injury or pressure points. e. Wear warm clothing when outside in cold weather.

a. Hypothalamus

Which of the following areas of the brain are responsible for temperature regulation? a. Hypothalamus b. Thalamus c. Pons d. Medulla

b. conduction

Which term describes the transfer of heat from the body to a cooler object in contact with it? a. radiation b. conduction c. lichenification d. evaporation

a. body temperature control

A client experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with: a. body temperature control b. balance and equilibrium c. visual acuity d. thinking and reasoning

b. lorazepam

A client experiencing alcohol withdrawl exhibits tremors, diaphoresis, and hyperactivity. Blood pressure is 190/87 mmHg, and pulse is 92 bpm. Which medication should the nurse expect to administer? a. haloperidol b. lorazepam c. benztropine d. naloxone

b. Shivering

A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention? a. Capillary refill of 2 seconds b. Shivering c. Cool, dry skin d. Urine output of 100 mL/hr

d. Apply a warm air blanket, gradually increasing body temperature

A client undergoing coronary artery bypass surgery is subjected to intentional hypothermia. The client is ready for rewarming procedures. Which action by the nurse is appropriate? a. Temporarily set the OR temperature to 30 deg C. b. Place warm damp drapes on the client, replacing them every 5 minutes. c. Administer IV fluids warmed to room temperature. d. Apply a warm air blanket, gradually increasing body temperature.

c. elevated temperature

A client who had an exploratory laparotomy 3 days ago has a white blood cell (WBC) differential with a shift to the left. The nurse instructs unlicensed assistive personnel (UAP) to report which clinical manifestation of this laboratory report? a. swelling around the incision b. redness around the incision c. elevated temperature d. purulent wound drainage

b. Dantrolene

A client with a history of malignant hyperthermia is scheduled for surgery. Which agent would the nurse MOST likely expect to administer? a. Botulinum toxin type B b. Dantrolene c. Baclofen d. Methocarbarnol

c. Heatstroke

The older adult will have an increased risk for developing which of the following? a. Fire hazards b. Gunshot wounds c. Heatstroke d. Poisoning