Thermoregulation

Axillary temperature is about ____than the oral temperature.

0.55°C (1.0°F) less

Normal body temperature

98.6 F (37 C)

4. A nurse has an order to take the core temperature of a patient. At which of the following sites would a core body temperature be measured? A) tympanic B) oral C) axillary D) skin surface

A Tympanic

_____is the most effective means of reducing a fever in a client with a head injury.

A cooling blanket

A nurse is obtaining vital signs from patients using the tympanic method for measuring temperature. Which client should the nurse avoid use o the tympanic method when obtaining a termperature reading? A. A client that has an ear infection with pain B. A client that has cerumen in the ear canal C. A client that has a ear piercing D. A client that wears hearing aids

A. A client that has an ear infection with pain

A 6-year-old child is brought to the clinic by his parents. The parents state, "He had a sore throat for a couple of days and now his temperature is over 102°F (38.9°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. Diphtheria C. Community-acquired methicillin-resistant Staphylococcus aureus (CAMRSA) D. Pertussis

A. Scarlet fever

A hospital unit has a policy that rectal temperatures may not be taken on patients who have had cardiac surgery. What rationale supports this policy? A) It is an embarrassing and painful assessment. B) Thermometer insertion stimulates the vagus nerve. C) It is less expensive to take oral temperatures. D) It is to avoid perforating the wall of the rectum.

B- Thermometer insertion stimulates the vagus nerve

Victims of a boating accident were admitted to the hospital with the diagnosis of hypothermia. What should the nurse realize as the method by which these clients lost body temperature? A) Vaporization B) Insensible water loss C) Convection D) Insensible heat loss

C) Convection Convection is the process of losing heat through the movement of air or water molecules across the skin.

The nurse is taking the client's temperature. The nurse understands that the rectal route is one of the most reliable. Which client can safely handle the rectal route of taking temperature? A) a client who is short of breath just by using the restroom B) a 9-month old infant who has been crying for the past 2 hours C) the 65-year old male who just finished drinking coffee D) the client who is vomiting

C) the 65-year old male who just finished drinking coffee

An Asian American client is experiencing a fever. The nurse recognizes that the client is likely to self-treat the disorder, using which method? A. Prayer B. Magnetic therapy C. Foods considered to be yin D. Foods considered to be yang

C. Foods considered to be yin

All of the following patients have a body temperature of 38°C (100.4°F). About which patient would a nurse be most concerned ?A) an older adult C) a junior high football player B) a pregnant adolescent D) a 2-month-old infant

D. A 2 month old infant

What is a function of brown adipose tissue (BAT) in newborns?

Generates heat for distribution to other parts of body

A nurse is planning care for a client coming into the emergency department via ambulance on a hot summer day with the following symptoms: temperature of 105°F (40.5°C), absence of sweating, and loss of consciousness. The nurse anticipates that the client has which condition?

Heat stroke

What site for taking body temperature with a glass thermometer is contraindicated in clients who are unconscious? A. OralB. RectalC. AxillaryD. Tympanic

Oral

During the surgical procedure, the client's temperature falls to 96.6°F. Which of the following nursing actions is inappropriate? Warm IV and irrigating fluids. Increase the temperature of the OR environment. Remove wet gowns and drapes. Place a cooling blanket under the client.

Place a cooling blanket under the client.

The ___ remains the most common place for temperature measurement in the neonate

axilla

The transfer of heat to another object during direct contact

conduction

hyperpyrexia

fever is equal to or greater than 41°C (106°F)

Which intervention is an appropriate action by a nurse to take in attempting to decrease a client's temperature through conduction? o Lower the room temeprature Remove the client's blankets Apply cooling blanket Give client a warm bath

Apply cooling blanket

A client postoperative from an appendectomy reports feeling cold and has a temperature of 96.2 degrees Fahrenheit. Which action should the nurse do first? Check the client?s blood pressure. Apply an oxygen saturation monitor. Apply warm blankets to the client. Notify the health care provider.

Apply warm blankets to the client.

A nurse places a fan in the room of a patient who is overheated. This is an example of heat loss related to which of the following mechanisms of heat transfer? A) evaporation B) radiation C) conduction D) convection

Convection

The dissemination of heat by motion between areas of unequal density

Convection

A newborn is placed in an open crib in the newborn nursery, which is located near the doorway to the hall. What type of heat loss would this infant experience? conductive evaporative convective radiant

Convection Convective heat loss occurs when air currents blow across the infant's body, causing it to chill. By placing the infant near a doorway, the infant will be exposed to drafts. Conductive heat loss occurs with direct contact with a cold surface. Evaporative heat loss occurs with moisture evaporating from the body. Radiant heat loss occurs with being close to a cold object but not touching it.

Remittent

Fluctuating fever that remains elevated; it does not return to baseline temperature.

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? Administer prescribed IV mannitol. Suction the child. Encourage the parent to talk to the child. Administer prescribed rectal acetaminophen.

Administer prescribed IV mannitol.

The nurse has just measured an adult patient's oral temperature and obtained a result of 102.4ºF (39.1ºC). The patient states, "I just finished my coffee right before you came in. Can I have another cup?" Which of the following responses by the nurse is most appropriate? "I will bring you another cup when I return in 30 minutes to reassess your temperature. Please do not drink any other beverages until I return." "You will need to remain NPO until I notify your primary healthcare provider about your increased temperature." "Before you drink another hot beverage, drink some cool water so I can obtain an accurate oral temperature." "I'll be right back with your coffee and a different thermometer. I'm not sure this one measured your temperature correctly."

"I will bring you another cup when I return in 30 minutes to reassess your temperature. Please do not drink any other beverages until I return."

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. "It is because of the closely woven, dark fabric wrapped around the baby" B. "It is common for newborns to have body temperatures less than 36.4°C (97.6°F)" C. "It is because of the immature ability to regulate temperature in general." D. "The baby is showing how it is adapting to the environmental temperature.

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

A home healthcare nurse notices that his assigned patient uses a mercury thermometer. He asks the nurse what to do if it breaks. Which of the following is not correct?A) "Just flush the glass and mercury down the toilet."B) "Do not vacuum the area where it breaks."C) "Open the windows and close off the room for an hour."D) "Throw away any clothing exposed to the mercury."

"Just flush the glass and mercury down the toilet.

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

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

The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2° F. What is the priority nursing action? A. Document the findings .B. Retake the temperature in 15 minutes. C. Notify the health care provider (HCP) .D. Increase hydration by encouraging oral fluids.. Increase hydration by encouraging oral fluids.

Increase hydration by encouraging oral fluids.. Increase hydration by encouraging oral fluids.

Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. The findings are indicative of which nursing diagnosis? Acute incisional pain Ineffective thermoregulation Decreased cardiac output Ineffective airway clearance

Ineffective thermoregulation

A child is admitted to the hospital with a febrile seizure. What action should the nurse take? Keep the child supine. Place the child in isolation. Keep the room temperature low and bedclothes to a minimum. Place a padded tongue blade at the bedside.

Keep the room temperature low and bedclothes to a minimum. One nursing goal for a child with febrile seizures is to maintain the child's temperature at a level low enough to prevent recurrence of seizures. Decreasing the environmental temperature and removing excess clothing and blankets will help decrease the child's temperature.

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.

Massage frostbite areas to rewarm them and increase circulation.

Intermittent

The body temperature returns to normal at least once every 24 hours.

Assessing a rectal temperature

The rectal temperature, a core temperature, is considered to be one of the most accurate routes.- The rectal site should not be used in newborns, children with diarrhea, and in patients who have undergone rectal surgery or have a disease of the rectum. -Because the insertion of the thermometer into the rectum can slow the heart rate by stimulating the vagus nerve, assessing a rectal temperature for patients with heart disease or after cardiac surgery may not be allowed in some institutions. -In addition, assessing a rectal temperature is contraindicated in patients who are neutropenic (have low white blood cell counts, such as in leukemia) and in patients who have certain neurologic disorders (e.g., spinal cord injuries) .-Do not insert a rectal thermometer into a patient who has a low platelet count. The rectum is very vascular, and a thermometer could cause rectal bleeding

The nurse planning care for a patient with hypothermia would consider knowledge of similar exemplars includinga. heat exhaustion. b. heat stroke. c. infection. d. prematurity.

d. prematurity.

The body gives off waves of heat from uncovered surfaces.

radiation

What are two ways in which newborn loss heat?

radiation and convection

relapsing or recurrent fever

The body temperature returns to normal for one or more days with one or more episodes of fever, each as long as several days.

A student is reading the medical record of an assigned patient and notes the patient has been afebrile for the past 12 hours. What does the term "afebrile" indicate? normal body temperature decreased body temperature increased body temperature fluctuating body temperature

Normal body temperature

7. Which of the following is an average normal temperature in Centigrade for a healthy adult? A) oral: 37.0°C B) rectal: 36.5°C C) axillary: 37.5°C D) tympanic: 34.4°C

Oral 37C

When teaching a group of parents about the potential for febrile seizures in children, which information should the nurse include? The exact cause is known. The seizures occur as the fever rises. Children older than age 3 years are most at risk. These seizures commonly occur after immunization administration.

The seizures occur as the fever rises.

Physical effects of Fever

-Patients with fever may experience loss of appetite; headache; hot, dry skin; flushed face; thirst; muscle aches; and fatigue. -Respirations and pulse rate increase. -Young children with high fevers may experience seizures and older adults may have periods of confusion and delirium. -Fever blisters may develop in some people as the fever activates the type I herpes simplex virus.- Fluid, electrolyte, and acid-base imbalances are potentially dangerous complications of fever.

Which of the following should the nurse include in the discharge plan for a client with multiple sclerosis who has an impaired peripheral sensation? Select all that apply. 1. Carefully test the temperature of bath water. 2. Avoid kitchen activities because of the risk of injury. 3. Avoid hot water bottles and heating pads. 4. Inspect the skin daily for injury or pressure points. 5. Wear warm clothing when outside in cold temperatures.

1. Carefully test the temperature of bath water. 3. Avoid hot water bottles and heating pads. 4. Inspect the skin daily for injury or pressure points. 5. Wear warm clothing when outside in cold temperatures.

How does core body temp differ from surface body temp?

Core temperature is higher than surface temp core temp is one F more than surface

When assessing an infant's axillary temperature, it will be One degree lower than an oral temperature One degree higher than a rectal temperature One degree higher than an oral temperature The same as the tympanic temperature

One degree lower than an oral temperature

An 80-year-old client has a body temperature of 97°F. Which condition best accounts for this client's temperature reading?

Temperature drops with age

The Older client who has pneumonia has a normal body temperature. The client's daughter asked the nurse why is temperature normal when she has an infection?

Temperature is normal b/c older clients have a lower baseline body temperature so even with infection temperature can fall into normal limits.