NCLEX Thermoregulation Questions

Which are modes of heat loss in the newborn? Select all that apply. 1. Radiation 2. Urination 3. Convection 4. Conduction 5. Evaporation

Answer: 1, 3, 4, 5 Radiation, Convection, Conduction, Evaporation

The nurse is performing a physical assessment on a client during her first prenatal visit to the clinic. The nurse takes the client's temperature and notes that the temperature is 99.2° F. Based on this finding, which nursing action is most appropriate? 1. Document the temperature. 2. Notify the health care provider. 3. Retake the temperature by the rectal route. 4. Inform the client that the temperature is elevated and antibiotics may be required.

Answer: 1. Document the temperature.

The nurse is performing an assessment on a client with a diagnosis of myxedema (hypothyroidism). Which assessment finding should the nurse expect to note in this client? 1. Dry skin 2. Thin, silky hair 3. Bulging eyeballs 4. Fine muscle tremors

Answer: 1.Dry skin

The nurse is monitoring a client with Graves' disease for signs of thyrotoxic crisis (thyroid storm). Which signs or symptoms, if noted in the client, will alert the nurse to the presence of this crisis? 1. Fever and tachycardia 2. Pallor and tachycardia 3. Agitation and bradycardia 4. Restlessness and bradycardia

Answer: 1.Fever and tachycardia

The nurse is developing a plan of care for an older client that addresses interventions to prevent cold discomfort and the development of accidental hypothermia. The nurse should document which desired outcome in the plan of care? 1. The client's body temperature is 98° F. 2. The client's fingers and toes are cool to touch. 3. The client remains in a fetal position when in bed. 4. The client complains of coolness in the hands and feet only.

Answer: 1.The client's body temperature is 98° F

The nurse is performing an assessment on a client with a diagnosis of hyperthyroidism. Which assessment finding should the nurse expect to note in this client? 1. Dry skin 2. Bulging eyeballs 3. Periorbital edema 4. Coarse facial features

Answer: 2. Bulging eyeballs

A client visits the health care provider's office for a routine physical examination and reports a new onset of intolerance to cold. Since hypothyroidism is suspected, which additional information would be noted during the client's assessment? 2. Complaints of weakness and lethargy 3. Diaphoresis and increased hair growth 4. Increased heart rate and respiratory rate

Answer: 2. Complaints of weakness and lethargy

The nurse is caring for a child after surgical removal of a brain tumor. The nurse should assess the child for which sign that would indicate that brainstem involvement occurred during the surgical procedure? 1. Inability to swallow 2. Elevated temperature 3. Altered hearing ability 4. Orthostatic hypotension

Answer: 2. Elevated temperature

A client treated for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client states a need to perform which action? 1. Increase fluid intake. 2. Resume full activity level. 3. Stay in a cool environment when possible. 4. Monitor voiding for adequacy of urine output.

Answer: 2. Resume full activity level.

The nurse has applied a hypothermia blanket to a client with a fever. A priority for the nurse is to inspect the skin frequently to detect which complication of hypothermia blanket use? 1. Frostbite 2. Skin breakdown 3. Venous insufficiency 4. Arterial insufficiency

Answer: 2. Skin breakdown

The nursing instructor asks a nursing student to identify the risk factors associated with the development of thyrotoxicosis. The student demonstrates understanding of the risk factors by identifying an increased risk for thyrotoxicosis in which client? 1. A client with hypothyroidism 2. A client with Graves' disease who is having surgery 3. A client with diabetes mellitus scheduled for a diagnostic test 4. A client with diabetes mellitus scheduled for débridement of a foot ulcer

Answer: 2.A client with Graves' disease who is having surgery

A nurse has a prescription to administer a medication to a client who is experiencing shivering as a result of hyperthermia. Which medication should the nurse anticipate to be prescribed? 1. Buspirone (BuSpar) 2. Chlorpromazine (Thorazine) 3. Prochlorperazine (Compazine) 4. Fluphenazine (Prolixin Decanoate)

Answer: 2.Chlorpromazine (Thorazine)

Which interventions are appropriate when administering a tepid bath to a child with a fever? Select all that apply. 1. Allow the child's skin to air dry. 2. Apply alcohol-soaked cloths over the child's body. 3. Use a water toy to distract the child during the bath. 4. Place lightweight pajamas on the child after the bath. 5. Squeeze water over the child's body, using the washcloth.

Answer: 3, 4, 5 Use a water toy to distract the child during the bath, Place lightweight pajamas on the child after the bath, Squeeze water over the child's body, using the washcloth

The nurse in the newborn nursery is preparing to complete an initial assessment on a newborn infant who was just admitted to the nursery. The nurse should place a warm blanket on the examining table to prevent heat loss in the infant caused by which method? 1. Radiation 2. Convection 3. Conduction 4. Evaporation

Answer: 3. Conduction

The nurse assisted with the delivery of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? 1. Warming the crib pad 2. Closing the doors to the room 3. Drying the infant with a warm blanket 4. Turning on the overhead radiant warmer

Answer: 3. Drying the infant w a warm blanket

An Asian American client is experiencing a fever. The nurse recognizes that the client is likely to self-treat the disorder, using which method? 1. Prayer 2. Magnetic therapy 3. Foods considered to be yin 4. Foods considered to be yang

Answer: 3. Foods considered to be yin

A client with a neurological problem is experiencing hyperthermia. Which measure would be least appropriate for the nurse to use in trying to lower the client's body temperature? 1. Giving tepid sponge baths 2. Applying a hypothermia blanket 3. Placing ice packs in the axilla and groin areas 4. Administering acetaminophen (Tylenol) per protocol

Answer: 3. Placing ice packs in the axilla and groin areas

A client who is receiving therapy with a hypothermia blanket starts to shiver. The nurse raises the blanket temperature and monitors the client. After 15 minutes the client's temperature has not increased and the client is still shivering. What should the nurse do next? 1. Apply a smaller heating pad to the client's axillae and neck areas. 2. Wait 10 more minutes and then check the client's temperature again. 3. Remove the hypothermia blanket and notify the client's health care provider (HCP). 4. Increase the blanket's temperature again and recheck the client's temperature in 15 minutes.

Answer: 3. Remove the hypothermia blanket and notify the client's health care provider (HCP).

A client arrives at the postpartum unit after delivery of her infant. On performing an assessment, the nurse notes that the client is shaking uncontrollably. Which nursing action would be appropriate? 1. Massage the fundus. 2. Contact the health care provider. 3. Cover the client with a warm blanket. 4. Place the client in Trendelenburg's position.

Answer: 3.Cover the client with a warm blanket.

A newborn is delivered via spontaneous vaginal delivery. On reception of the crying newborn, the nurse's priority is to perform which action? 1. Determine Apgar score. 2. Auscultate the heart rate. 3. Thoroughly dry the newborn. 4. Take the newborn's rectal temperature.

Answer: 3.Thoroughly dry the newborn.

A client complains of being cold, and the nurse notes the presence of "goose flesh" on the client's arms. The nurse plans care, knowing that which structure is responsible for this response? 1. Arterioles 2. Sweat glands 3. Collagen fibers 4. Arrector pili muscles

Answer: 4. Arrector pili muscles

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? 1. Document the findings. 2. Retake the temperature in 15 minutes. 3. Notify the health care provider (HCP). 4. Increase hydration by encouraging oral fluids.

Answer: 4. Increase hydration by encouraging oral fluids

The nurse has just administered ibuprofen (Motrin) to a child with a temperature of 38.8° C (102° F). The nurse should also take which action? 1. Withhold oral fluids for 8 hours. 2. Sponge the child with cold water. 3. Plan to administer salicylate (aspirin) in 4 hours. 4. Remove excess clothing and blankets from the child.

Answer: 4. Remove excess clothing and blankets from the child.

The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who is experiencing night fever and night sweats. Which nursing intervention would be the least helpful in managing this symptom? 1. Keep liquids at the bedside. 2. Make sure the pillow has a plastic cover. 3. Keep a change of bed linens nearby in case they are needed. 4. Administer an antipyretic after the client has a spike in temperature.

Answer: 4.Administer an antipyretic after the client has a spike in temperature.

A nurse is assigned to the care of a client hospitalized with a diagnosis of hypothermia. The nurse anticipates that the client will exhibit which findings on assessment of vital signs? 1. Increased heart rate and increased blood pressure 2. Increased heart rate and decreased blood pressure 3. Decreased heart rate and increased blood pressure 4. Decreased heart rate and decreased blood pressure

Answer: 4.Decreased heart rate and decreased blood pressure

The nurse is caring for an unconscious client who is experiencing persistent hyperthermia with no signs of infection. The nurse interprets that the hyperthermia may be related to damage to the client's thermoregulatory center in which structure? 1. Cerebrum 2. Cerebellum 3. Hippocampus 4. Hypothalamus

Answer: 4.Hypothalamus

A client's baseline vital signs are as follows: temperature 98.8° F oral, pulse 74 beats/min, respirations 18 breaths/min, and blood pressure 124/76 mm Hg. The client's temperature suddenly spikes to 103° F. Which corresponding respiratory rate should the nurse anticipate in this client as part of the body's response to the change in status? 1. Respiratory rate of 12 breaths/min 2. Respiratory rate of 16 breaths/min 3. Respiratory rate of 18 breaths/min 4. Respiratory rate of 22 breaths/min

Answer: 4.Respiratory rate of 22 breaths/min