Prep U and Other Practice Questions (Thermoregulation)

When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction? - "Restrict fluid intake to 1,500 ml/day." - "Limit your fruit and vegetable intake." - "Avoid taking daytime naps." - "Avoid hot baths and showers."

"Avoid hot baths and showers." Explanation: The nurse should instruct a client with MS to avoid hot baths and showers because they may exacerbate the disease. The nurse should encourage daytime naps because fatigue is a common symptom of MS. A client with MS doesn't require food or fluid restrictions.

The nurse provided teaching to an older adult client about fevers. Which client statement indicates that the teaching was​ effective? A. "The rectal route is the best way to have my temperature​ taken." B. "I may not have a fever when I get sick or have an​ infection." C. "I am less sensitive to environmental temperatures than when I was​ younger." D. "Cancer is the top source of fever in older​ adults."

B. "I may not have a fever when I get sick or have an infection." Rationale: Older adults do not exhibit the​ sign/symptom of fever with​ infection, as do younger persons.​ However, the top source of fever is still infection or an inflammatory​ process, not cancer. Rectal route for taking a temperature is not the best route due to discomfort and increased prevalence of hemorrhoids. Older adults are more sensitive to extreme environmental temperature changes due to decreased thermoregulatory controls.

The nurse is assessing a client who fell into a cold lake. Which assessment finding indicates that the​ client's body is attempting to regulate its​ temperature? (Select all that​ apply.) A. Sweating B. Cold hands C. Thirst D. Shivering E. Sleepiness

B. Cold hands D. shivers ​Rationale: When the skin is​ chilled, the body attempts to regulate temperature by vasoconstriction of blood vessels. This could be why the​ client's hands are cold. The body also shivers to increase heat production. The body does not regulate temperature through​ sleep, thirst, or by sweating.

The nurse observes a mother stroking her​ child's arms and legs with a​ cool, damp washcloth. Which method of heat transfer is the mother using to reduce the​ fever? A. Radiation B. Evaporation C. Conduction D. Metabolism

B. Evaporation Rationale: Heat can be transferred between places or objects. Evaporation is the conversion of water to​ vapor, which is what occurs when the mother applies cool water to the​ child's limbs. Radiation is the release of heat through no physical contact. Conduction is the release of heat through physical contact. Metabolism is not a method of heat transfer

A nurse is caring for a marathon runner who collapsed while running in extremely warm weather. Upon admission, the client's temperature is 102°F (38.9°C). What is the most appropriate nursing diagnosis? - Heat Exhaustion - Dehydration - Hyperthermia - Electrolyte Imbalance

Hyperthermia Explanation: Physical exertion during extremely warm weather can lead to various health problems. The client was admitted with a temperature of 102°F (38.9°C) evidencing Hyperthermia. Dehydration is the probable cause or etiology of the Hyperthermia. Heat Exhaustion is a lay term. Electrolyte Imbalance is a collaborative problem that requires physician's orders to treat.

Amniotic fluid is produced throughout the pregnancy by the fetal membranes. Amniotic fluid has four major functions. What is one of these functions? - Physical protection - Restriction of movement - Medium in which to test organ maturity - Provide fluid to keep the fetus hydrated

Physical protection Explanation: Amniotic fluid serves four main functions for the fetus: physical protection, temperature regulation, provision of unrestricted movement, and symmetrical growth.

A client has a mild headache and fatigue. He also states he has some aches and pains. Which stage of fever does the nurse determine the client is experiencing? - Prodrome - Defervescence - Flush - Chill

Prodrome Explanation: During the first or prodromal period there are nonspecific complaints such as mild headache and fatigue, general malaise, and fleeting aches and pains.

Which hormone is responsible for breast development and the increase in body temperature that occurs with ovulation? - Androgen - Testosterone - Progesterone - Prolactin

Progesterone Explanation: Progesterone is the hormone responsible for breast development and increase in body temperature during ovulation. The other options are not involved in either of these processes.

The nurse is constructing a teaching plan for the client newly diagnosed with scleroderma. What should the nurse include in the teaching plan? - Protect the hands and feet from cold. - Perform weight-bearing exercises daily. - Take all antibiotics until they are gone. - Avoid sunlight and ultraviolet light.

Protect the hands and feet from cold. Explanation: Raynaud's phenomenon is associated with scleroderma. Client teaching must include strategies for protecting the feet and hands.

The nurse needs to assess a 1-year-old child for fever. Which approach will produce the most accurate reading? - Oral - Forehead - Axillary - Rectal

Rectal Explanation: Measurement of core body temperature is important when evaluating fever. The rectal route is considered the most accurate. In adults and older children, the oral route is lower, but still accurate; however, in young children the oral route may be unreliable. Forehead thermometers can predict trends, but are not as accurate as other routes. The axillary route requires up to 10 minutes for the temperature to register appropriately.

Antipyretic drugs, such as aspirin, ibuprofen, and acetaminophen, are often used to alleviate the discomforts of fever and protect vulnerable organs, such as the brain, from extreme elevations in body temperature. The use of aspirin is limited in children, however, because it can sometimes cause which disease? - Münchausen syndrome - Reye syndrome - Angelman syndrome - Guillain-Barré syndrome

Reye syndrome Explanation: Aspirin can cause Reyé syndrome in children; therefore, the Centers for Disease Control and Prevention, US Food and Drug Administration, and American Academy of Pediatrics Committee on Infectious Diseases advise against the use of aspirin and other salicylates in children with influenza or chickenpox. Münchausen syndrome is an unusual psychiatric condition characterized by habitual pleas for treatment and hospitalization for a symptomatic but imaginary acute illness. Guillain-Barré syndrome is an idiopathic, peripheral polyneuritis that occurs 1 to 3 weeks after a mild episode of fever associated with a viral infection or with immunization. Angelman syndrome is an autosomal recessive syndrome characterized by jerky puppet-like movements, frequent laughter, intellectual disability, motor retardation, a peculiar open-mouthed facial expression, and seizures.

A client is experiencing anorexia, myalgia, arthralgia, headache, and fatigue. The nurse should assess for: - Hypothermia - Temperature - Urinary output - Respirations

Temperature Explanation: Common clinical manifestations of fever include anorexia, myalgia, arthralgia, headaches, and fatigue; thus, the nurse should assess the client's temperature.

The nurse is caring for a patient with hyperthyroidism who suddenly develops symptoms related to thyroid storm. What symptoms does the nurse recognize that are indicative of this emergency? - Blood pressure 90/58 mm Hg - Oxygen saturation of 96% - Heart rate of 62 - Temperature of 102ºF

Temperature of 102ºF Explanation: Thyroid storm is characterized by the following: 1) high fever (hyperpyrexia), >38.5°C (>101.3°F); 2) extreme tachycardia (>130 bpm); 3) exaggerated symptoms of hyperthyroidism with disturbances of a major system—for example, gastrointestinal (weight loss, diarrhea, abdominal pain) or cardiovascular (edema, chest pain, dyspnea, palpitations); and 4) altered neurologic or mental state, which frequently appears as delirium psychosis, somnolence, or coma.

A client is being evaluated for hypothyroidism. During assessment, the nurse should stay alert for: - systolic murmur at the left sternal border. - flushed, warm, moist skin. - decreased body temperature and cold intolerance. - exophthalmos and conjunctival redness.

decreased body temperature and cold intolerance. Explanation: Hypothyroidism markedly decreases the metabolic rate, causing a reduced body temperature and cold intolerance. Other signs and symptoms include dyspnea, hypoventilation, bradycardia, hypotension, anorexia, constipation, decreased intellectual function, and depression. Exophthalmos; conjunctival redness; flushed, warm, moist skin; and a systolic murmur at the left sternal border are typical findings in a client with hyperthyroidism.

During a procedure, a client's temperature begins to rise rapidly. This is likely the result of which complication? - fluid volume excess - infection - hypothermia - malignant hyperthermia

malignant hyperthermia Explanation: Malignant hyperthermia is an inherited disorder that occurs when body temperature, muscle metabolism, and heat production increase rapidly, progressively, and uncontrollably in response to stress and some anesthetic agents. If the client's temperature begins to rise rapidly, anesthesia is discontinued, and the OR team implements measures to correct physiologic problems, such as fever or dysrhythmias. Hypothermia is a lower than expected body temperature. Signs of infection would not present during the procedure. Increased body temperature would not indicate fluid volume excess.

Which finding is indicative of hypothermia of the preterm neonate? - pink skin - regular respirations - nasal flaring - oxygen saturation of 95%

nasal flaring Explanation: Nasal flaring is a sign of respiratory distress. Neonates with hypothermia show signs of respiratory distress (cyanosis, increased respirations, low oxygen saturation, nasal flaring, and grunting). The other choices are normal findings.

Hypothermia may occur as a result of - increased muscle activity. - open body wounds. - the infusion of warm fluids. - being young.

open body wounds. Explanation: Inadvertent hypothermia may occur as a result of a low temperature in the OR, infusion of cold fluids, inhalation of cold gases, open wounds or cavities, decreased muscle activity, advanced age, or particular pharmaceutical agents.

A client is being treated for increased intracranial pressure (ICP). The nurse should ensure that the client does not develop hypothermia because: - hypothermia is indicative of severe meningitis. - hypothermia can cause death to the client. - hypothermia is indicative of malaria. - shivering in hypothermia can increase ICP.

shivering in hypothermia can increase ICP. Explanation: Care must be taken to avoid the development of hypothermia because hypothermia causes shivering. Shivering, in turn, can increase intracranial pressure.

A nurse is monitoring a premature neonate for development of neonatal sepsis. Which assessment finding is an early sign of neonatal sepsis? - hypotension - temperature instability - gastric retention - blood in the stool

temperature instability Explanation: Neonatal sepsis is oftentimes difficult to diagnose because many of the symptoms are nonspecific in the beginning. Sometimes the nurse uses intuition and experience and describes the baby as "not looking right." One of the first signs of sepsis is that the infant cannot maintain temperature and becomes hypothermic. Other symptoms include pallor, poor feeding, irritability, apnea and bradycardia, respiratory distress, and abdominal distention. Hypotension may be seen in neonatal sepsis, but it is a late sign, not an early sign. In infants and children, the blood pressure is the last vital sign to exhibit a change. If hypotension has occurred, the infant is already very ill. Gastric retention and blood in the stool are signs of necrotizing enterocolitis and should be monitored closely in infants who are at risk.

A nurse is assessing a postpartum client and notes an elevated temperature. Which temperature protocol should the nurse prioritize? - 100.3ºF (37.9ºC) at 24 hours postbirth and remains the same for the second postpartum day - 100.5ºF (38.1ºC) at 48 hours postbirth and remains the same the third day postpartum - 100.1ºF (37.8ºC) at 24 hours postbirth and decreases the second postpartum day - 99.1ºF (37.3ºC) at 12 hours postbirth and decreases after 18 hours

100.5ºF (38.1ºC) at 48 hours post birth and remains the same the third day postpartum Explanation: A temperature that is greater than 100.4ºF (38ºC) on two postpartum days after the first 24 hours puts the client at risk for a postpartum infection. A fever in the first 24 hours of birth is considered normal and could be caused by dehydration and analgesia.

When assessing an infant's axillary temperature, it will be: - the same as the tympanic temperature. - 1°F (0.5°C) lower than an oral temperature. - 1°F (0.5°C) higher than a rectal temperature. - 1°F (0.5°C) higher than an oral temperature.

1°F (0.5°C) lower than an oral temperature. Explanation: Rectal temperatures may be 1°F (0.5°C) higher than oral temperatures and axillary temperatures are 1°F (0.5°C) lower than oral temperatures.

A patient with frostbite to both lower extremities from exposure to the elements is preparing to have rewarming of the extremities. What intervention should the nurse provide prior to the procedure? - Elevate the legs. - Massage the extremities. - Apply a heat lamp. - Administer an analgesic as ordered.

Administer an analgesic as ordered. Explanation: During rewarming, an analgesic for pain is administered as prescribed, because the rewarming process may be very painful. To avoid further mechanical injury, the body part is not handled. Massage is contraindicated.

Which of the following measures can be used to cool a burn? - Application of cool water - Apply ice - Wrap the person in ice - Use cold soaks

Application of cool water Explanation: Once a burn has been sustained, the application of cool water is the best first-aid measure. Never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns.

On a​ hot, humid​ day, a client presents with a body temperature of​ 40.9°C (105.6°F), dry and flush​ skin, vomiting, low blood​ pressure, and muscle cramps. Which type of injury should the nurse suspect based on the​ manifestations? A. Malignant hyperthermia B. Heat stroke C. Hypothermia D. Normothermia

B. Heat stroke Rationale: The nurse should suspect heat​ stroke, which can occur during hot weather and high humidity and results in dysfunction of the​ brain's thermoregulation center. Signs and symptoms of​ heat-related injuries include​ paleness, dizziness, nausea and​ vomiting, fatigue, low blood​ pressure, muscle​ cramps, and fainting. Late signs include​ irritability, confusion,​ stupor, and coma. Hypothermia is a core body temperature below​ 35°C (95°F), and is classified as​ mild, 32dash-​35°C ​(89.6dash-​95°F); ​moderate, 28dash-​32°C ​(82.4dash-​89.6°F), or​ severe, below​ 28°C (less than​ 82.4°F). The usual range of core body temperature is called normothermia. The normal range for adults is between​ 36°C and​ 38.5°C (96.8°F and​ 101.3°F). Malignant hyperthermia is a potentially​ fatal, inherited disorder that results from the​ body's reaction to volatile inhalation of anesthetic gases and​ succinylcholine, a depolarizing neuromuscular blocker.

Which intervention would be the best way for the nurse to prevent heat loss in a newborn while bathing? - Postpone breastfeeding until after the initial bath. - Bathe the baby in water between 90 and 93 degrees. - Bathe the baby under a radiant warmer. - Limit the bathing time to 5 minutes.

Bathe the baby under a radiant warmer. Explanation: Bathing a newborn under a radiant warmer helps to prevent heat loss. To minimize the effects of cold stress during the bath, the nurse should also prewarm blankets, dry the child completely to prevent heat loss from evaporation, encourage skin-to-skin contact with the mother, promote early breastfeeding, used heated and humidified oxygen, and defer bathing until the newborn is medically stable. Limiting the length of time spent bathing the baby is secondary to maintaining the baby's body temperature. Having warm water is also important but is irrelevant if the baby is not kept warm under a warmer.

A school nurse is recommending a​ school-wide initiative to reduce the risk of​ heat-related injuries in athletes. Which recommendation should the nurse​ include? A. Cancel athletic games when the temperature is above 80degrees°F. B. Reduce athletic activities at the school. C. Increase access to​ fresh, cold water. D. Encourage the school to move athletic activities indoors.

C. Increase access to fresh, cold water ​Rationale: Increasing access to fresh cold water and encouraging frequent water breaks can decrease the risk of hyperthermia. It is highly unlikely that the school will reduce athletic​ activities, and it may not be possible to cancel games when the temperature is above​ 80°F. The school may not have the facilities to host indoor​ athletics, and it​ doesn't address the needs of athletes when they play at other locations.

Which client should not have a temperature assessed rectally? - Client with ALS - Client with diarrhea - Client with cancer - Client with a herniated disc

Client with diarrhea Explanation: The rectal route is contraindicated in clients with diarrhea, those who have undergone rectal surgery, those with rectal diseases, and those with cancer who are neutropenic.

Which term describes the transfer of heat from the body to a cooler object in contact with it? - Radiation - Conduction - Lichenification - Convection

Conduction Explanation: Conduction is one of the three major physical processes are involved in loss of heat from the body to the environment. Radiation is the transfer of heat to another object of lower temperature situated at a distance. Lichenification is the leather thickening of the skin. Convection consists of movement of warm air molecules away from the body.

An older adult client asks the​ nurse, "Why is my body temperature only​ 99°F if I have this serious​ infection?" Which is the​ nurse's best​ response? A. "Your body temperature fluctuates​ significantly, so a true temperature is difficult to​ obtain." B. "I will to take your temperature​ rectally, since it is the only reliable route in somebody your​ age." C. "The true temperature will not register because you are a mouth​ breather." D. "Body temperature in an older adult is not a reliable indicator of the seriousness of an​ illness."

D. "Body temperature in an older adult is not a reliable indicator of the seriousness of an illness."​ Rationale: Body temperature may not be a valid indication of serious illness in an older adult. The older adult may have an infection and exhibit only a slight temperature elevation. Other​ symptoms, such as confusion and​ restlessness, may be present. These require​ follow-up to determine whether an underlying disease process is present. There is no evidence to support that the client is a mouth breather. Rectal temperatures in older adult clients may be contraindicated if hemorrhoids are present. Body temperature in an older adult does not fluctuate significantly.