Nursing Concept - Thermoregulation
A nurse is caring for a client with hypothermia and frostbite of the nose and fingers. Which action by the nurse is inappropriate for this client? A) Massage frostbite areas to rewarm them and increase circulation. B) Rapidly rewarm affected areas in circulating warm water. C) Keep the client on bedrest with the affected parts elevated. D) Debride blisters.
A Explanation: A nurse should never massage frostbite areas, as this action will further damage necrotic tissue. All other choices are appropriate nursing interventions for a client with frostbite.
In the past, a college campus in a cold climate has had multiple students require treatment for mild hypothermia during the winter months. Which method would be most effective for the campus nurse to use to promote healthy thermoregulation on this campus? A) Show a video about the harmful effects of hypothermia due to exposure. B) Put up posters encouraging students to wear hats and mittens. C) Sell inexpensive pocket handwarmers in the campus bookstore.
A Explanation: College students are mostly likely to pay attention to a video compared to other media choices, and showing a video about the harmful effects of hypothermia due to exposure may be effective for many students who wouldn't pay attention to the other options. College students are likely to ignore posters telling them to wear hats and mittens. Alcohol consumption increases the risk of exposure due to poor choices, which then increases the risk for hypothermia. Students may not have money to purchase handwarmers, and they may not even know they are available for purchase in the bookstore without some advertisement.
A client who has experienced head trauma may undergo induced hypothermia for what purpose? A) To reduce metabolic rate and oxygen need B) To reduce the risk of internal bleeding C) To reduce the risk of a brain hemorrhage D) To reduce glycogen consumption
A Explanation: Hypothermia is induced following head trauma to reduce metabolic rates and lower cellular demand for oxygen in the tissues, particularly the brain. Historically, this reduces neurologic damage. Glycogen needs are increased in hypothermia, and the risk of internal bleeding and hemorrhage is not reduced.
A client is admitted to the emergency department complaining of the inability to feel the hands and feet after exposure to 20°F temperatures for more than 2 hours. Which action by the nurse is appropriate? A) Warm the hands and feet in 104°F water for 20 to 30 minutes. B) Provide an antipyretic. C) Rub and massage the hands and feet. D) Warm the hands and feet in tepid water for 2 hours.
A Explanation: The client's inability to feel his hands and feet after spending 2 hours in 20°F weather would indicate the client is experiencing frostbite. Rapid thawing decreases tissue necrosis and should be done by warming the hands and feet in circulating 104°F water for 20 to 30 minutes. The hands and feet should not be rubbed. Tepid water will not rapidly warm the hands and feet. Antipyretics would be indicated for a fever.
Why are interval vital sign measurements an important prevention measure for hyperthermia in the clinical setting? A) They are useful for monitoring for infection and inflammation. B) They are important for establishing a client's baseline temperature. C) They are essential to determining the cause of a fever of unknown origin. D) They are helpful for monitoring a client's reaction to antipyretics.
A Explanation: The nurse should use interval vital sign measurement to monitor for infections and inflammation, which are common causes of fever. Often, the most effective prevention activities start with graphing the vital sign data to identify a pattern or trend in the temperature rising or falling over time.
The nurse is caring for a 73-year-old client. When assessing temperature, which finding would the nurse report immediately to the provider as a potential sign of sepsis? A) The client's temperature is below his baseline temperature. B) The client's temperature is above his baseline temperature. C) The client's temperature is at his baseline temperature. D) The client's temperature is fluctuating with each measurement.
A Explanation: Older adults frequently do not present with a fever that coincides with the significance of an infection, and, in fact, temperatures below the older adult's baseline may accompany sepsis.
A young adult client is admitted to the emergency department with symptoms of hypothermia. Which data collected during the health history supports this diagnosis? A) The client was wearing a coat when the EMTs found him. B) The client had a blood alcohol level of 0.12. C) The client forgot to eat lunch. D) The client was wearing a winter hat at the time of admission.
B Explanation: Alcohol causes peripheral vasodilation, which exposes the circulating bloodstream to more rapid cooling, resulting in a faster decrease in body temperature. The client's intake of alcohol contributed to the development of hypothermia. Skipping a meal would not cause hypothermia. Wearing a coat and hat are ways to prevent hypothermia.
The nurse assists with the examination of a newborn in the newborn nursery. Prior to placing the child on the exam table, she spreads a cotton pad over the surface. By doing so, the nurse is protecting against heat loss by which method? A) Convection B) Conduction C) Evaporation D) Radiation
B Explanation: Conduction is the process of heat transfer through physical contact of one surface to another surface. This is the method of heat loss that occurs when a newborn baby is placed on a bare surface. Convection is the process of heat transfer through the fluid motion of air or water across the skin. Evaporation is the process of converting water to a vapor. Radiation is the process of heat transfer with no physical contact.
The nurse is planning to instruct a new mother on ways to prevent hypothermia in her newborn. What should this teaching include? A) Expect the baby to shiver. B) Keep the newborn's head covered with a hat. C) Cover the newborn with a light sheet during afternoon naps. D) Cover the newborn with minimal blankets when out of doors in temperatures in the 50s.
B Explanation: Covering the newborn's head will help reduce heat loss. The newborn should be swaddled in a blanket of appropriate weight during naps and when outdoors in cool temperatures. Shivering is not expected and means that the baby's metabolic rate has doubled.
A hospitalized client with a body temperature of 104°F is entering the flush phase of the fever. Which action by the nurse is appropriate when providing care? A) Restricting fluids. B) Monitoring intake and output. C) Covering the client with warm blankets. D) Providing warmed intravenous fluids.
B Explanation: During the flush phase of a fever, the client's body is attempting to adjust the temperature set-point lower. Nursing measures are implemented in order to aid the body in reestablishing a core temperature compatible with normal cellular functioning. The nurse must diligently monitor the client's intake and output to addresses changes in hydration state. Restricting fluids could lead to dehydration and a higher body temperature. Warm blankets and warm intravenous fluids will increase the body's temperature.
A client has been receiving treatment for hypothermia. Which evaluation finding indicates nursing interventions have been successful? A) Current temperature of 95°F B) Heart rate of 72 and regular C) Continues to shiver D) Blood pressure of 88/54 mmHg
B Explanation: Evidence of successful treatment for hypothermia is a heart rate of 72 (which is within normal limits) and regular. The other findings indicate a continued low body temperature.
When flushing occurs in a client with a fever, what underlying mechanism to restore normal temperature is occurring? A) Increased metabolism B) Vasodilation C) Insensible water loss D) Increased thyroxine output
B Explanation: Flushing is redness of the skin that occurs when blood vessels vasodilate in order to bring more blood flow to the body's surface. This allows the air's cooler temperature to reduce the temperature of the blood flow as heat dissipates through convection.
The nurse is caring for a client who is experiencing hyperthermia. Which intervention is appropriate for this client? A) Applying warm blankets B) Administering a prescribed antipyretic medication C) Keeping limbs close to the body D) Covering the scalp with a hat
B Explanation: Hyperthermia is the medical term for an increase in body temperature. An appropriate intervention for a client experiencing hyperthermia is to administer a prescribed antipyretic medication, such as acetaminophen. Applying warm blankets, keeping the limbs close to the body, and covering the scalp with a hat are all appropriate interventions for a client who is experiencing hypothermia.
Which hormone is responsible for epinephrine release and thus chemical thermogenesis? A) Norepinephrine B) Thyroxine C) Progesterone D) Aldosterone
B Explanation: Increased thyroxine levels cause an increase in the release of epinephrine. Norepinephrine does not cause epinephrine release. Progesterone maintains pregnancy and aldosterone regulates electrolyte and water balance; neither is involved in chemical thermogenesis.
A client is receiving care for an elevated body temperature. Which assessment findings indicate that care has been effective? Select all that apply. A) Urine output of 20 mL/hour B) Moist mucous membranes C) Heart rate of 120 beats per minute D) Good skin turgor E) Blood pressure of 118/68 mmHg
B, D Explanation: Evidence that interventions have been effective for a client with an elevated body temperature includes moist mucous membranes and good skin turgor. Urine output of 20 mL/hour indicates dehydration. Blood pressure of 118/68 mmHg is not an indication of the control of fever. A heart rate of 120 beats per minute could indicate dehydration.
A client is started on antibiotic therapy for a respiratory infection. Which goal is appropriate for this client? A) The client will have no evidence of sweating. B) The client's mucous membranes will be dry. C) The client's temperature will be within normal limits within 48 to 72 hours of the administration of the antibiotic. D) The client's temperature will approach normal within 60 minutes of the administration of the antibiotic.
C Explanation: A goal of care for a client receiving antibiotic therapy for an infection is for the temperature to be within normal limits within 48 to 72 hours after starting the antibiotic. The temperature approaching normal within 60 minutes would be an appropriate goal if the client were receiving antipyretics. Sweating is evidence that the temperature is decreasing, a desired outcome. Dry mucous membranes are evidence of an elevated temperature and are not a desired outcome.
What is the primary means of assessing the severity of hyperthermia? A) Core temperature measurement B) Skin temperature measurement C) Clinical presentation of the client D) Client history related to current condition
C Explanation: Clinical presentation of the client should determine the severity of hypothermia, and all clients diagnosed with hypothermia should undergo a complete body survey. Severity of hypothermia should not be determined based on temperature measurement, as methods of measuring temperature and degree of accuracy may differ. History may be useful for determining causative factors, but not severity of condition.
The nurse is caring for a client who presents to the emergency department after a boating accident in which the client nearly drowned. The nurse understands that which type of heat loss resulted in a diagnosis of hypothermia? A) Evaporation B) Insensible water loss C) Convection D) Insensible heat loss
C Explanation: Convection is the process of heat transfer through the fluid motion of air or water across the skin. The clients of a boating accident developed hypothermia through convection. Evaporation is the process of converting water to a vapor, and the evaporation of sweat transfers the heat in the sweat to the air. Insensible water loss is unnoticed water loss through evaporation. Insensible heat loss is the loss of heat through evaporation.
A nurse working in an outpatient pediatric clinic is speaking to the mother of a school-age client who has a temperature of 101°F with a normal appearance and few signs of discomfort. Which statement should the nurse include when instructing the mother on treatment of the fever? A) "Place the child in a cold bath." B) "Administer aspirin by either chewable tablet or liquid suspension." C) "It is not necessary to treat the fever at this point." D) "If your child is shivering, it is okay to use several blankets to decrease discomfort."
C Explanation: Fever is not inherently harmful until it reaches 41°C (105.9°F). For this reason, medical management may include postponing treatment of low-grade fevers—those under 38.9°C (102°F) in otherwise healthy children. The child may be placed in a tepid, not cold, bath. Aspirin should not be given to children due to its link to Reye syndrome. Reducing clothing and blankets, not additional layers, aids in the treatment of fever.
A 31-year-old pregnant client in her second trimester of pregnancy presents in the doctor's office with a fever of 102°F. The client is extremely upset and concerned that her elevated temperature may harm her unborn child. Which statement should the nurse include when explaining the client's risk? A) "Maternal fever is only problematic when it reaches 103° or higher, but temperatures below this level are generally not a concern." B) "Maternal fever is not associated with birth defects; rather, the medication taken to reduce the fever may cause problems." C) "Maternal fever is a concern during pregnancy, but the risk to the child is greatest during the first trimester." D) "Maternal fever is not associated with birth defects, but other types of hyperthermic exposure are associated with them."
C Explanation: Hyperthermic exposure and maternal fever in the first trimester of pregnancy have been associated with congenital defects. Studies indicate that it is the fever itself—not medication or maternal illness—that is associated with such defects. A temperature of 101.3° or greater is considered a fever.
A nurse is working in the labor and delivery unit. What statement does the nurse understand is true regarding newborn thermogenesis? A) Shivering occurs when skin receptors perceive a drop in the environmental temperature and transmit sensations to stimulate the sympathetic nervous system. B) Shivering thermogenesis uses the newborn's stores of brown fat to provide heat. C) Brown fat produces heat generation, and heat transfer to the peripheral circulation. D) The extra muscular activity by the infant in cold stress produces a large amount of body heat.
C Explanation: In the infant, non-shivering thermogenesis (NST) occurs when skin receptors perceive a drop in the environmental temperature and transmit sensations to stimulate the sympathetic nervous system. NST uses the newborn's stores of brown fat to provide heat. Brown fat produces heat generation and heat transfer to the peripheral circulation. The extra muscular activity by the infant in cold stress does not produce body heat.
A nurse working in a gerontologist's office is reviewing the files of patients who have appointments today. Of these patients, which one should the nurse identify as having the lowest risk for developing hypothermia? A) An 80-year-old client with hypothyroidism and a lengthy medication regimen B) A 69-year-old client with type 2 diabetes mellitus and peripheral neuropathy C) A 78-year-old client who regularly walks and does strength training with small hand weights D) A 75-year-old client with decreased subcutaneous fat and several dietary restrictions
C Explanation: Lack of activity is an environmental risk factor for hypothermia in older results, so the active older adult is at a lower risk for hypothermia. Chronic conditions such as diabetes, peripheral neuropathy, and hypothyroidism increase risk. Medication use, inadequate diet, and decreased subcutaneous fat also increase risk.
The nurse is caring for an older adult client who was admitted with pneumonia. The client's vital signs are: P 84, R 22, BP 118/74, T (oral) 98.3°F. The client asks the nurse to explain how she can have an infection without having a fever. How should the nurse respond? A) The cool temperature of the hospital room helps prevent fevers. B) The client was likely misdiagnosed and does not have an infection. C) The body's ability to respond to changes in temperature declines with age. D) The loss of body heat associated with pneumonia reduces the risk of fever.
C Explanation: Older adults' temperatures may not be a valid indication of an infectious process. Other symptoms such as confusion and restlessness may be a more accurate indicator. A normal body temperature does not indicate that the client does not have pneumonia. The client may or may not be losing body heat. It is not known whether the room is or is not cold.
The nurse needs to assess the body temperature of a client who has just smoked a cigarette and consumed hot coffee. Which temperature assessment method should the nurse use? A) Axillary B) Temporal artery C) Tympanic D) Rectal
C Explanation: Since the oral method cannot be used because the client smoked a cigarette and consumed hot coffee, the assessment method of choice would be the tympanic membrane. This method is readily accessible and reflects the core temperature very quickly. The rectal method is inconvenient and uncomfortable for clients. The temporal artery method requires special electronic equipment. The axillary method takes a long time if an accurate measurement is to be obtained.
A client is admitted to the emergency department with a body temperature of 103°F. It is a hot and humid day, and the client works outside in the sun. Which actions by the nurse are appropriate when providing care to this client? Select all that apply. A) Use warm blankets. B) Restrict fluids. C) Apply cool washcloths to the face and neck. D) Assess vital signs. E) Remove or loosen clothing around the neck and chest.
C, E Explanation: Until the client has orders written, the nurse can apply cool washcloths to the client's face and neck to increase comfort and reduce the client's body temperature. The nurse can also reduce clothing and skin covering by loosening clothing around the neck and chest. Warm blankets and fluid restriction would keep the temperature elevated rather than helping to decrease it. Assessing vital signs is important; however, the nurse needs to intervene to help bring the body temperature down.
A nursing student is discussing thermoregulation with fellow students. Which statement about thermoregulation does the student recognize as being true? A) "Core temperature varies widely depending on the outside environment." B) "The body's surface temperature remains relatively constant." C) "Chemical thermogenesis occurs with the increase of cortisol." D) "All muscle activity, regardless of location, produces heat."
D Explanation: All muscle activity, regardless of location, produces heat. Core temperature remains relatively constant, whereas the body's surface temperature varies widely depending on the outside environment. Chemical thermogenesis occurs with increased output of thyroxine, not cortisol.
The nurse is providing care to a client who is experiencing an elevated body temperature. Which class of medication does the nurse anticipate will be prescribed for this client? A) Anticholinergic B) Antihypertensive C) Antiemetic D) Antipyretic
D Explanation: Antipyretic medication is used to reduce the body temperature. Antihypertensives are used to reduce blood pressure. Antiemetics are used to reduce nausea and vomiting. Anticholinergics reduce acetylcholine activity.
During an assessment, the nurse notes that a client who was a victim of an industrial accident has a mildly elevated body temperature. When discussing the client's increased temperature, which will the nurse attribute it to? A) Infection B) Diet C) Exercise D) Stress
D Explanation: Factors that affect body temperature include age, diurnal variations, exercise, hormones, stress, and environment. The client who is a victim of an industrial accident most likely has a temperature elevation because of stress. There is no evidence presented to indicate infection. The client was not exercising. Diet does not influence body temperature
The nurse is educating a family who is planning an ice fishing trip on ways to prevent hypothermia. Which recommendation by the nurse is appropriate? A) All family members should wear skid-proof footwear. B) If someone becomes hypothermic, sponge tepid water onto any exposed skin. C) All family members should wear light rain jackets. D) If someone becomes hypothermic, remove any wet clothing, wrap the person in blankets, and have the person drink a warm liquid.
D Explanation: First aid for hypothermia includes moving the person to a dry area, removing wet clothing, protecting the person from further environmental exposure, wrapping the person in dry blankets, dressing the person in warm and dry clothing, and having the person drink a warm, high-calorie liquid. Skid-proof footwear and light rain jackets will not prevent hypothermia. Tepid water is used in cases of hyperthermia, not hypothermia.
A client is admitted with a core body temperature of 93°F. Which action by the nurse is appropriate for this client? A) Apply warm soaks to the extremities. B) Use a hypothermia blanket. C) Provide warm fluids. D) Use warm blankets.
D Explanation: For mild hypothermia, or a body temperature of 89.6-95°F, use warm blankets. A hypothermia blanket is used when treating hyperthermia, not hypothermia. Warm soaks to extremities will not raise the client's body temperature and might cause chilling. Providing warm fluids is beneficial, but not enough to raise the client's body temperature.
A client presents in the emergency department with a core body temperature of 88.8°F. The nurse understands that this temperature indicates this patient is A) normothermic. B) mildly hyperthermic. C) febrile. D) moderately hypothermic.
D Explanation: Hypothermia occurs when core body temperature is below 95°F and is classified as moderate between 82.4°F and 89.6°F. Normothermia occurs when body temperature falls between 96.8°F and 101.3°F. Hyperthermia occurs when body temperature is above 101.3°F. A hyperthermic patient may be described as febrile.
A nurse is caring for a client with a fever who is experiencing tachypnea. Which is true regarding this client's condition? A) The decrease in prostaglandin production causes the respiratory rate to increase. B) Although it sometimes occurs, an increased respiratory rate is not a common reaction to fever. C) One degree of temperature elevation causes an increase in respiratory rate by two breaths per minute. D) One degree of temperature elevation causes an increase in respiratory rate by four breaths per minute.
D Explanation: Increased respiratory rate always occurs with a fever. Every one degree of temperature elevation causes an increase in respiratory rate of four breaths per minute. Prostaglandin production increases, not decreases, during fever.
A client has a body temperature of 96°F and exhibits slurred speech and poor coordination. Which is the priority nursing diagnosis for this client? A) Risk for Thermal Injury B) Hyperthermia C) Hypothermia D) Risk for Imbalanced Body Temperature
D Explanation: The client is demonstrating signs of a reduction in body temperature. The nursing diagnosis appropriate at this time is Risk for Imbalanced Body Temperature. A body temperature of or below 95°F would indicate hypothermia. A body temperature above 101.3°F would indicate hyperthermia. The client is not at risk for thermal injury.
The nurse is providing care to a client who has a body temperature of 94°F, an irregular heart rate, and low blood pressure. Which is the priority intervention for this client? A) Elevate the client's legs. B) Provide a heating pad to the client's lower back. C) Elevate the head of the bed. D) Administer warmed intravenous fluids.
D Explanation: The client is mildly hypothermic with symptoms of an irregular heartbeat and low blood pressure. Warmed intravenous fluids would be beneficial for this client. Elevating the legs or the head of the bed will not help with the client's hypothermia. A heating pad to the lower back is not indicated in the treatment of hypothermia.
A client is admitted with the diagnosis of fever of unknown origin. Which diagnostic test does the nurse anticipate for this client? A) CT scan of the abdomen B) Bone scan C) Glucose tolerance test D) Complete blood count
D Explanation: The diagnostic tests will focus on trying to find the cause of the elevated body temperature. The complete blood count will be done to see if there is an elevation in white blood cells, indicative of infection. A bone scan, a glucose tolerance test, and a CT scan of the abdomen may or may not be indicated for this client.
The nurse is caring for a client admitted with minor burns and elevated body temperature after being in a house fire. What should be included in this client's plan of care to address the elevated body temperature? Select all that apply. A) Providing blankets B) Keeping the room temperature warm C) Restricting fluids D) Encouraging fluids E) Lowering room temperature
D, E Explanation: The client with an elevated body temperature should be encouraged to ingest fluids or should be provided with IV fluids. The increase in body temperature could be due to dehydration. Another intervention to help the client with an elevated temperature is to lower the room temperature. The client's fluids should not be restricted. Blankets and providing a warm room would be applicable if the client had a low body temperature
A client is experiencing an elevated temperature due to a viral illness. What should the nurse anticipate being included in this client's plan of care? Select all that apply. A) Administer warm intravenous fluids. B) Apply warm blankets. C) Keep limbs close to body. D) Increase fluid intake. E) Administer antipyretic medication.
D, E Explanation:The client has an elevated temperature. The administration of antipyretic medication is one treatment used to lower the body temperature. Increasing fluid intake is another intervention for an elevated body temperature. The other options would be interventions to help a client with a low body temperature.
