138: Thermoregulation EAQs
Which antipyretic medication may cause Reye syndrome in children? 1 Aspirin (Anacin) 2 Naproxen (Aleve) 3 Ibuprofen (Advil) 4 Dantrolene (Dantrium)
1 Aspirin (Anacin) increases the risk of swelling in the brain and liver, which are the main symptoms of Reye syndrome in children. Therefore aspirin is not recommended in children. Drugs such as naproxen (Aleve) and ibuprofen (Advil) do not induce swelling in the brain and liver; therefore, these drugs may not cause Reye syndrome. Dantrolene (Dantrium) does not induce swelling in the brain and liver; instead, it decreases calcium levels during malignant hyperthermia conditions.
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
1 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 presents to the emergency department with weakness and dizziness. The blood pressure is 90/60 mm Hg, pulse is 92 and weak, and body weight reflects a 3-pound (1.4 kilogram) loss in two days. The weather has been hot. Which condition should the nurse conclude is the priority for this client? 1 Deficient fluid volume 2 Impaired skin integrity 3 Inadequate nutritional intake 4 Decreased participation in activities
1 The low blood pressure indicates hypovolemia, the increased pulse is an attempt to maintain adequate oxygenation of tissues, and the rapid weight loss reflects loss of body fluid. Although impaired skin integrity is a concern with dehydration, it is not the priority. The rapid weight loss reflects a loss of fluid, not a loss of body tissue. Although the client may need assistance with activities, an inadequate intake of fluid has caused the client's dehydration, which is a serious medical problem that needs to be treated immediately. Topics
Which symptoms are common during the fulminant stage of inhalation of anthrax? Select all that apply. 1 Dyspnea 2 Dry cough 3 Diaphoresis 4 Mild chest pain 5 High temperature
1,3,5 The fulminant stage of inhalation of anthrax is manifested by dyspnea, diaphoresis, and a high body temperature. The prodromal stage of inhalation of anthrax is manifested by a dry cough and mild chest pain.
What are the signs and symptoms observed in the human body with a decrease in body temperature? Select all that apply. 1 Shivering 2 Profuse sweating 3 Flushed appearance 4 Dilation of blood vessels 5 Contraction of blood vessels
1,5 A client who has decreased body temperature may experience shivering due to contraction of the blood vessels in the body. The client who has decreased body temperature may not experience profuse sweating, flushed appearance, and dilated blood vessels. These signs and symptoms appear with an increase in body temperature.
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
2 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. Topics
A client experiencing chills and fever is admitted to the hospital. After assessing the client's vitals and medical history, the nurse concluded that the client's fever pattern is remittent. Which assessment finding led to this conclusion? 1 The client's temperature returns to an acceptable value at least once in the past 24 hours 2 The client's fever spikes and falls without a return to normal temperature levels 3 Periods of febrile episodes and periods with acceptable temperature values occur 4 The client has a constant body temperature continuously above 38°C with minimal fluctuation
2 In a remittent pattern of fever, the fever spikes and falls without a return to normal temperature levels. If the temperature returns to an acceptable value at least once in a 24 hour interval, the fever has an intermittent pattern. Periods of febrile episodes and periods with acceptable temperature values is a relapsing type of fever. In a sustained fever, the body temperature is constantly above 38°C and has little fluctuation.
The parent of a preterm infant asks the nurse in the neonatal intensive care unit why the baby is in a bed with a radiant warmer. How does the nurse explain the increased risk for hypothermia in preterm infants? 1 Have a smaller body surface area than full-term newborns 2 Lack the subcutaneous fat that usually provides insulation 3 Perspire excessively, causing a constant loss of body heat 4 Have a limited ability to produce antibodies against infections
2 Much of a full-term infant's birth weight (almost a third) is gained during the last month of gestation, and most of this final spurt is related to an increase in subcutaneous fat, which serves as insulation; the preterm infant did not have enough time to grow in the uterus and therefore has little of this insulating layer. Preterm infants do not shiver or sweat. The preterm infant has a relatively larger surface area per body weight than does a term infant. Depressed antibody production is unrelated to maintenance of body temperature.
Which parts of the body assessed by the nurse would confirm a diagnosis of frostbite? Select all that apply. 1 Axilla 2 Fingers 3 Ear lobes 4 Forehead 5 Upper thorax
2,3 Areas particularly susceptible to frostbite are the fingers, toes, and earlobes. These parts of the body should be assessed to determine frostbite. The axilla is generally used to assess the body temperature; this site is used to diagnose a fever. The forehead and upper thorax are assessed to detect diaphoresis.
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? 1 Covering the infant with a bath blanket 2 Sponging the infant with tepid alcohol 3 Removing excess clothing from the infant 4 Reassessing the infant's temperature in several hours
3 After the initial safety measures and notification of the practitioner have been addressed, excess clothing, which prevents heat loss, should be removed. Covering the infant will increase the temperature because heat loss will be reduced. Alcohol should never be used for infants or children; it causes severe chilling, which can lead to increased metabolic activity and a higher temperature. This high fever requires more frequent readings, usually at least every hour.
While obtaining the vital signs of a client, the nurse finds that the body temperature of the client is 98.6 °F. The nurse concludes that the client is experiencing what? 1 Hypothermia 2 Hyperpyrexia 3 Hyperthermia 4 Normothermia
4 A body temperature of 98.6 °F is normal. Therefore the nurse concludes that the client has normothermia. The client does not have low body temperature, or hypothermia. The client's body temperature does not exceed the normal range; therefore, the client does not have hyperpyrexia or hyperthermia.
Which is a characteristic of the glands that secrete a thick substance in response to emotional stimulation and become odoriferous because of bacterial action? 1 Highly active in childhood 2 Absent around the umbilicus 3 Widely distributed throughout the body 4 Grow in conjunction with axillary hair follicles
4 The apocrine sweat glands secrete a thick substance in response to emotional stimulation and become odoriferous because of bacterial action. These glands grow in conjunction with hair follicles around the axillae. The apocrine glands are inactive during childhood and reach their secretory potential at the time of puberty. The apocrine glands are situated around the umbilicus. They have limited distribution and are found only around the axillae, areolae, external auditory canal, and anal and genital regions. Eccrine sweat glands, not the apocrine glands, have wide distribution throughout the body.
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
1 Gradually rewarming an infant experiencing cold stress is essential to avoid compromising the infant's cardiopulmonary status. It is not necessary to notify the practitioner initially. It is the nurse's responsibility to rewarm the infant. An infant experiencing cold stress will become hypoglycemic because glycogen and glucose are metabolized to maintain the core temperature. Skin temperature should be taken at least every 15 minutes until stable.
Body temps
Hypothermia is classified as mild hypothermia (body temperature of 34 °C to 36 °C/93.2 °F to 96.8 °F), moderate hypothermia (body temperature of 30 °C to 34 °C/86 °F to 93 °F), and severe hypothermia (body temperature below 30 °C/86 °F). Client B, with a body temperature of 85.3 °F, is in need of rewarming through cardiopulmonary bypass because his or her body temperature is less than 86 °F. Clients A, C, and D do not have a temperature less than 86 °F; therefore, they may not need rewarming through cardiopulmonary bypass.