Thermoregulation

A school-age child with a severe head injury is unconscious and has coarse breath sounds, a temperature of 39° C (102.2° F), a heart rate of 70 bpm, a blood pressure of 130/60 mm Hg, and an intracranial pressure (ICP) of 36 mm Hg. Which action should the nurse perform first? A. Administer prescribed IV mannitol. B. Suction the child. C. Encourage the parent to talk to the child. D. Administer prescribed rectal acetaminophen.

A. Administer prescribed IV mannitol.

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 temperatures.

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 temperatures.

The nurse is preparing the delivery room before the birth occurs. What supplies would the nurse have available to care for the newborn? Select all that apply. A. Warmer bed B. Glucose water C. Suction equipment D. Identification bands E. Ophthalmoscope

A. Warmer bed C. Suction equipment D. Identification bands

A pregnant client is undergoing a fetal biophysical profile. Which parameter of the profile helps measure long-term adequacy of the placental function? A. amniotic fluid volume B. fetal heart rate C. fetal breathing record D. fetal reactivity

A. amniotic fluid volume

The nurse should give which discharge instructions about thermal injury to a client with peripheral vascular disease? Select all that apply. A. "Warm the fingers or toes by using an electric heating pad." B. "Avoid sunburn during the summer." C. "Wear extra socks in the winter." D. "Choose loose, soft, cotton socks." E. "Use an electric blanket when you are sleeping."

B. "Avoid sunburn during the summer." C. "Wear extra socks in the winter." D. "Choose loose, soft, cotton socks."

The nurse is conducting a physical assessment of a homeless man during a night when the wind chill factor is -10°F (-23°C). When assessing the man's fingers and toes for frostbite, the nurse looks for which type of cellular injury? A. Mechanical B. Hypoxic C. Chemical D. Endogenous

B. Hypoxic

A young client has a temperature of 102℉ (38.9℃). The nurse is treating the fever with nonpharmacologic methods, in addition to the scheduled antipyretic the child received, by removing the blanket that covers the child. What is the rationale for this action? A.The blanket adds heat to the child. B. Removing excess coverings allows for evaporation, which aids in cooling the child. C. The blanket soaks up the sweat, making the child warmer. D. Covering the child with a blanket leads to shivering, which will only generate more heat.

B. Removing excess coverings allows for evaporation, which aids in cooling the child.

A client experiencing alcohol withdrawal exhibits tremors, diaphoresis, and hyperactivity. Blood pressure is 190/87 mm Hg, and pulse is 92 bpm. Which medication should the nurse expect to administer? A. haloperidol B. lorazepam C. benztropine D. naloxone

B. lorazepam

A nurse is monitoring a client post cardiac surgery. What action would help to prevent cardiovascular complications for this client? A. Position the client in bed with pillows placed under his knees to hasten venous return. B. Keep the client from ambulating until the day after surgery. C. Implement leg exercises and turn the client in bed every 2 hours. D. Keep the client cool and uncovered to prevent elevated temperature.

C. Implement leg exercises and turn the client in bed every 2 hours.

What site for taking body temperature with a glass thermometer is contraindicated in patients who are unconscious? A. rectal B. tympanic C. oral D. axillary

C. oral