PrepU-Thermoregulation
When developing the plan of care for a neonate, what measure should the nurse include to prevent heat loss from conduction?
Warm the stethoscope before using it.
When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction?
"Avoid hot baths and showers."
A nurse is assessing a newborn at the healthcare 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?
"It is because of the immature ability to regulate temperature in general."
A female client is being treated for increased intracranial pressure (ICP). Why should the nurse ensure that the client does not develop hypothermia? Choose the correct option.
Because shivering in hypothermia can increase ICP
Which of the following is the term for the transfer of heat from the body to a cooler object in contact with it?
Conduction
A person's core body temperature is highest in the early morning and lowest in the late afternoon.
False
An elderly client is admitted to the facility after fainting while gardening on a hot summer day. Which nursing diagnosis takes highest priority for this client?
Hyperthermia
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?
Ineffective thermoregulation
A client who takes neuroleptic medication for treatment of chronic schizophrenia is admitted to the psychiatric unit. Nursing assessment reveals rigidity, fever, hypertension, and diaphoresis. Which life-threatening reaction do these findings suggest?
Neuroleptic malignant syndrome
Just after delivery, a nurse measures a neonate's axillary temperature at 94.1°F (34.5°C). What should the nurse do?
Rewarm the neonate gradually.
Which of the following is often the earliest sign of malignant hyperthermia?
Tachycardia
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
A client experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with:
body temperature control.
A toddler hospitalized with nephrotic syndrome has marked dependent edema and hypoalbuminemia. His urine is frothy. When assessing the child's vital signs, the nurse should report which finding to the primary care provider?
body temperature of 102.8° F (39.3° C)
A client who had an exploratory laparotomy 3 days ago has a white blood cell (WBC) differential with a shift to the left. The nurse instructs unlicensed assistive personnel (UAP) to report which clinical manifestation of this laboratory report?
elevated temperature
The nurse is assessing a middle-aged client with cancer who has lost 1 lb (0.5 kg) in 4 weeks. The client is taking ondansetron for nausea and now has a temperature of 101° F (38.3° C). The fever is indicative of:
infection
A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to:
rest in an air-conditioned room.
What organ is the primary site of heat loss in the body?
skin
The nurse is caring for a child who sustained a spinal cord injury in a motor vehicle accident. The child's body temperature fluctuates markedly, and the parents question why this is occurring. What is the most accurate response for the nurse to give to the parents?
"The child's sympathetic nervous system was damaged in the accident."
The nurse is caring for a client who had an open cholecystectomy 24 hours ago. The client's vital signs have been stable over the last 24 hours, with most recent temperature 98.6° F (37° C), blood pressure (BP) 118/76 mm Hg, respiratory rate (RR) 16/min, and heart rate (HR) 78 bpm, but are now changing. Which set of vital signs indicates that the nurse should contact the health care provider (HCP)?
temperature 101.8° F (38.8° C), BP 140/86 mm Hg, HR 94 bpm, RR 24/min
