Thermoregulation chapters

The nurse instructs a client recovering from a mastectomy on ways to prevent lymphedema. Which client statement indicates that teaching has been successful? A) "I should do the exercises on my affected arm every day." B) "I have to take no special precautions." C) "I should avoid cleansing my skin with soap." D) "Eating fresh fruits and vegetables will prevent my arm from swelling."

A) "I should do the exercises on my affected arm every day." Range-of-motion exercises in the affected arm help develop collateral drainage and prevent the development of lymphedema.

A client is admitted to the emergency department complaining of the inability to feel the hands and feet after exposure to 20°F temperatures for more than 2 hours. Which action by the nurse is appropriate? A) Warm the hands and feet in 104°F water for 20 to 30 minutes. B) Provide an antipyretic. C) Rub and massage the hands and feet. D) Warm the hands and feet in tepid water for 2 hours.

A) Warm the hands and feet in 104°F water for 20 to 30 minutes. The client's inability to feel his hands and feet after spending 2 hours in 20°F weather would indicate the client is experiencing frostbite. Rapid thawing decreases tissue necrosis and should be done by warming the hands and feet in circulating 104°F water for 20 to 30 minutes. The hands and feet should not be rubbed. Tepid water will not rapidly warm the hands and feet. Antipyretics would be indicated for a fever.

A pregnant woman at 10 weeks gestation is being screen for colorectal cancer, which statement by the nurse accurately presents to the client the diagnostic challenge? A. "Diagnostic imaging is limited due to risks of harming the fetus" B. "Diagnostic imaging can be done only during last trimester of pregnancy" C. "Tumor marker level (CEA) may not be accurate, but it will not injure the fetus" D. "Ultrasound imaging is impeded by uterine growth and may affect the fetus"

A. "Diagnostic imaging is limited due to risks of harming the fetus"

The nurse is providing community teaching related to risk factor for breast cancer for a group of young women. which woman might the nurse identify as being at higher risk for developing breast cancer at a young age? A. A 26-year-old woman who had a 32-year-old brother with breast cancer B. A 42-year-old woman who has a second cousin diagnosed with breast cancer at age 58 C. A 34-year-old woman who has breast fed four children D. A 28-year-old woman who received radiation for a spinal cord tumor at L3 during childhood

A. A 26-year-old woman who had a 32-year-old BROTHER (male highest risk factor) with breast cancer

The mother of a 13-day-old calls the nurse in the clinic and reports that the newborn has an axillary temperature of 38.7 C (101.8*F). which intervention should the nurse suggest to the mother? A. Bring the newborn to the emergency department for evaluation B. Administer acetaminophen and call back if the fever doesn't go away. C. take the temperature again orally after giving the newborn a cold bath. D. Put the newborn in warm clothing while the fever is present.

A. Bring the newborn to the emergency department for evaluation Any newborn younger than 4 weeks old with a fever should be admitted to the hospital for further evaluation and testing. It is not appropriate for the nurse to suggest just giving the baby a cool bath or administering acetaminophen or ibuprofen.

The nurse assists with the examination of a newborn in the newborn nursery. Prior to placing the child on the exam​ table, she spreads a cotton pad over the surface. By doing​ so, the nurse is protecting against heat loss by which​ method? A. Conduction B. Radiation C. Evaporation D. Convection

A. Conduction

The nurse is assessing a patient who reports feeling weak after running outside in a temperature of 95°F (35°C).The nurse should monitor for which sign of heatstroke? A. Confusion B. Excitability C.Loss of sensation D.Pain

A. Confusions Confusion and weakness are two signs of severe heat-related injuries, such as heatstroke. Excitability is not a sign of a heat injury or other alteration of thermoregulation. Pain and loss of sensation are two signs of hypothermic injury.

The nurse is caring for a client who presents to the emergency department after a boating accident in which the client nearly drowned. The nurse understands that which type of heat loss resulted in a diagnosis of​ hypothermia? A. Convection B. Insensible water loss C. Insensible heat loss D. Evaporation

A. Convection

The nurse is instructing a group of women about early detection of breast cancer. What should the nurse include in this teaching? A. Have mammograms based on ACA recommendations B. Notify health care provider if there is a strong family history of breast cancer C. Be familiar with your breast tissue and notify health care provider of any change D. Have a clinical breast exam performed by a healthcare provider every 5 years.

A. Have mammograms based on ACA recommendations

A nurse is caring for a client with cancer. The nurse teaches the client about which potentially undesirable cellular alterations that can occur during the cell cycle? Select all that apply. A) Hyperplasia B) Differentiation C) Anaplasia D) Dysphagia E) Adaptation

A. Hyperplasia C. Anaplasia Explanation: Potentially undesirable cellular alterations that can occur during the cell cycle include hyperplasia and anaplasia. Hyperplasia is an increase in the number or density of normal cells, while anaplasia is the regression of a cell to an immature or undifferentiated cell type. Differentiation is a normal process occurring over many cell cycles that allows cells to specialize in certain tasks. Dysphagia and adaptation are not a part of the cell cycle. Page Ref: 34

The nurse assesses a​ client's temperature to be​ 99.8°F. Which nursing diagnosis would be appropriate for the client at this​ time? A. Risk for Imbalanced Body Temperature B. Hyperthermia C. Anxiety D. Deficient Fluid Volume

A. Risk for imbalanced body temperature Rationale: The​ client's temperature is slightly​ elevated, which places the client at risk for an imbalance in body temperature. Hyperthermia would be indicated if the​ client's temperature were greater than​ 102°F. There is not enough information to determine whether the client is or is not experiencing anxiety or deficient fluid volume.

The nurse is providing health counseling to a 32 year old woman whose mammogram indicates that she has dense breast tissue. Which information should the nurse provide to this client concerning this finding and breast health? A. The presence of dense breast tissue increases the risk of breast cancer before the age of 45. B. Dense breast tissue is a protective effect for breast cancer in women with dense breast tissue are very low C. Dense breast tissue is very common at this age and does not affect breast health D. Precancerous cells are found in the dense breast tissue; thus, she should have further screening done for breast cancer.

A. The presence of dense breast tissue increases the risk of breast cancer before the age of 45.

Which statement by the nurse shows a need for Further education about the essentials of genetics? A. Two copies of a Y chromosome result in a female B. DNA molecules are made up of long sequences C. People have 46 chromosomes D. Identical twins have the same DNA

A. Two copies of a Y chromosome result in a female

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? (SATA) A. Cold hands B. Thirst C. Shivering D. Sweating

A. cold hands C. Shivering 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.

What independent nursing intervention is important for the nurse to implement for clients who have alteration and cellular regulation? A. help the client identify support systems B. suggest contacting the nurse's spiritual leader C. administer pain and other medications D. design A diet that provides proper nutrition

A. help the client identify support systems

A nursing student is discussing thermoregulation with fellow students. Which statement about thermoregulation does the student recognize as being​ true? A. ​"All muscle​ activity, regardless of​ location, produces​ heat." B. "The body's surface temperature remains relatively​ constant." C. ​"Chemical thermogenesis occurs with the increase of​ cortisol." D. ​"Core temperature varies widely depending on the outside​ environment."

A. ​"All muscle​ activity, regardless of​ location, produces​ heat."

A nurse working in an outpatient pediatric clinic is speaking to the mother of a pediatric client who has a temperature of​ 101°F. Which statement should the nurse include when instructing the mother on treatment of the​ fever? A. ​"It is not necessary to treat the fever at this​ point."​ B. "Administer aspirin by either chewable tablet or liquid​ suspension."​ C. "If your child is​ shivering, it is okay to use several blankets to decrease​ discomfort." D. ​"Place the child in a cold​ bath."

A. ​"It is not necessary to treat the fever at this​ point."​ Fever is not inherently harmful until it reaches​ 103. For this​ reason, medical management may include postponing treatment of​ low-grade fevers-those under​ 102° in otherwise healthy children. The child may be placed in a​ tepid, not​ cold, bath. Aspirin should not be given to children due to its link to​ Reye's syndrome. Reducing clothing and​ blankets, not additional​ layers, aids in the treatment of fever.

A client who has experienced head trauma may undergo induced hypothermia for what purpose? A) To reduce metabolic rate and oxygen need B) To reduce the risk of internal bleeding C) To reduce the risk of a brain hemorrhage D) To reduce glycogen consumption

A.To reduce metabolic rate and oxygen need Hypothermia is induced following head trauma to reduce metabolic rates and lower cellular demand for oxygen in the tissues, particularly the brain. Historically, this reduces neurologic damage. Glycogen needs are increased in hypothermia, and the risk of internal bleeding and hemorrhage is not reduced.

The nurse is providing care to a client who was recently diagnosed with breast cancer. The nurse is providing education regarding the possible treatment options. Which options will the nurse include in the teaching session? Select all that apply. A) Mastectomy B) Hormone therapy C) Lumpectomy D) Palliative care E) Radiation

ABCE Treatment options appropriate for a client newly diagnosed with breast cancer may include mastectomy, hormone therapy, lumpectomy, and radiation. Palliative care will only be implemented once the client's cancer is considered to be terminal in nature.

The nurse is caring for a client who is diagnosed with cancer. Which diagnostic tests may be helpful to assist with treatment options? Select all that apply. A) Tumor markers B) Urinalysis C) Physical assessment D) MRI E) Stool analysis

ABD Many diagnostic tests are helpful in determining treatment for cancer. An MRI, urinalysis, and tumor markers are all diagnostic tests that may be used to determine treatment for cancer. A stool analysis is not a diagnostic test listed to determine treatment for cancer. A physical assessment may be useful to determine how a client is responding to treatment, but it is not considered a diagnostic test.

The nurse provides an educational session for community members about the risk factors for colorectal cancer. Which participant statement indicates that teaching has been effective? Select all that apply. A) "There is a genetic link in the development of colorectal cancer." B) "People with other bowel diseases are at increased risk for developing this cancer." C) "Eating a diet high in red meat reduces the risk for developing this type of cancer." D) "Eating cereal fiber reduces the risk of developing colorectal cancer." E) "Taking aspirin and a multivitamin each day reduces the risk of colorectal cancer."

ABE Genetic factors are strongly linked to the risk for colorectal cancer. Family history of the disease increases an individual's risk for its development. Inflammatory bowel diseases increase the risk of colorectal cancer.

A nurse is caring for a client with chronic myeloid leukemia (CML) who is neutropenic. Which interventions will the nurse implement to ensure this client's safety? Select all that apply. A) Teach the client to maintain good personal hygiene. B) Encourage the client to eat a diet low in protein. C) Administer granulocyte colony-stimulating factor (G-CSF) as ordered. D) Administer neutrophil colony-stimulating factor (N-CSF) as ordered. E) Administer a prophylactic gram-negative antibiotic.

AC A client who is neutropenic has a decrease in the level of white blood cells (WBCs) and is susceptible to infection and/or disease. To ensure the safety of the client with neutropenia, the nurse will teach the client to maintain good personal hygiene, administer granulocyte colony-stimulating factor (G-CSF) as ordered, and administer a broad-spectrum antibiotic as ordered. The client should be taught to eat a diet high in protein, not low in protein.

The nurse is caring for an adolescent client with a strong family history of breast cancer. What should the nurse instruct the client regarding cancer prevention? Select all that apply. A) Encourage the client to learn more about the disease. B) Talk to family members who have the disease. C) Perform monthly breast self-examination. D) Teach the side effects of cancer treatment. E) Discuss cancer fears with the healthcare provider.

AC When there is a familial history of cancer, the family should be encouraged to learn more about the cancer. Talking to family members who have the disease will not help with early detection or prevention. In families with a history of breast cancer, the nurse should inform clients about breast self-examination.

The nurse is reviewing data collected during a health history and physical assessment and determines that a client is at risk for developing breast cancer. Which data supports this client's risk for developing breast cancer? Select all that apply. A) Age 60 B) Breastfed both children C) Sister had breast cancer D) Body mass index 22 E) Menopause at age 58

ACE The risk for developing breast cancer increases with age. Having a first-degree relative with breast cancer increases the risk. Menopause after the age of 55 also increases the risk for developing breast cancer. Breastfeeding and maintaining a normal body weight lower a person's risk for developing breast cancer.

The nurse is planning care for a client with acute myeloid leukemia (AML). Which diagnoses are priorities for this client to minimize the risk of complications associated with AML? Select all that apply. A) Risk for Infection B) Ineffective Thermoregulation C) Imbalanced Nutrition, Less than Body Requirements D) Fluid Volume Excess E) Risk for Bleeding

AE AML results in neutropenia (decreased neutrophils = risk of infection) and thrombocytopenia (decreased platelets, which leads to increased risk of bleeding). Therefore, actions to minimize these risks are priorities when caring for clients with AML. Unlike clients with other types of leukemia, the client with AML does not have a problem with fluid shifts, edema, heat intolerance, or weight loss that would require nursing intervention.

A female patient complains of a "scab that just won't heal" under her left breast. During your conversation, she also mentions chronic fatigue, loss of appetite, and slight cough, attributed to allergies. What are the nurse's next steps? a. Continue to conduct a symptom analysis to better understand the patient's symptoms and concerns. b. End the appointment and tell the patient to use skin protection during sun exposure. c. Suggest further testing with a cancer specialist and provide the appropriate literature. d. Tell her to put a bandage on the scab and set a follow-up appointment in one week.

ANS: A. Continue to conduct a symptom analysis to better understand the patient's symptoms and concerns. A comprehensive health history is vital to treating and caring for the patient. Often times, symptoms are vague. The nurse should conduct a symptom analysis to gather as much information as possible. Questions should address the duration of the symptoms and include the location, characteristics, aggravating and relief factors, and any treatments taken thus far.

The nurse would incorporate which of the following into the plan of care as a primary prevention strategy for reduction of the risk for cancer? a. Yearly mammography for women aged 40 years and older b. Using skin protection during sun exposure while at the beach c. Colonoscopy at age 50 and every 10 years as follow-up d. Yearly prostate specific antigen (PSA) and digital rectal exam for men aged 50 and over

ANS: B Primary prevention of cancer involves avoidance to known causes of cancer, such as sun exposure. Secondary screening involves physical and diagnostic examination.

The most appropriate measure for a nurse to use in assessing core body temperature when there are suspected problems with thermoregulation is a(n) a. oral thermometer. b. rectal thermometer. c. temporal thermometer scan. d. tympanic membrane sensor

ANS: B The most reliable means available for assessing core temperature is a rectal temperature, which is considered the standard of practice. An oral temperature is a common measure but not the most reliable. A temporal thermometer scan has some limitations and is not the standard. The tympanic membrane sensor could be used as a second source for temperature assessment.

A client with anemia is prescribed synthetic erythropoietin. When teaching the client about the therapeutic effect of this treatment, which is appropriate for the nurse to include? A) Increase in platelets B) Increase in red blood cells C) Decrease in white blood cells D) Decrease in lymph fluid

Answer: B Explanation: Erythropoietin is a hormone produced in the body to stimulate production of red blood cells; synthetic forms are available for administration to cancer clients or others with significantly low red blood cell counts. Erythropoietin will not stimulate or decrease the production of platelets, white blood cells, or lymph fluid. Page Ref: 35

A nurse educator is teaching student nurses about methods of cellular transport. When instructing on passive transportation, which process will the nurse include in the teaching plan? A) Endocytosis B) Facilitated diffusion C) Exocytosis D) Phagocytosis

Answer: B Explanation: Passive cellular transportation does not require energy and includes facilitated diffusion, diffusion, osmosis, and filtration. Active cellular transportation requires energy and includes active transport pumps, endocytosis, phagocytosis, pinocytosis, and exocytosis. Page Ref: 32

A client has been receiving care for an elevated body temperature. Which assessment finding or findings indicate that care has been effective? Select all that apply. A) Urine output of 20 ml/hour B) Moist mucous membranes C) Heart rate of 120 beats per minute D) Good skin turgor E)Blood pressure of 118/68 mmHg

B) Moist mucous membranes D) Good skin turgor

The nurse is listing consequence of malignant hyperthermia Which of the following can be a result of malignant hyperthermia . (SATA). A. Gastroenteritis B. Cardiac dysrhythmias C. Renal-failure D. Coma E. Cancer

B, C, D Malignant hyperthermia is an inherited disorder that affects temperature regulation. With this​ condition, an individual experiences a serious reaction to inhaled anesthetic gases and depolarizing neuromuscular blockers. If not​ treated, the individual will develop renal​ failure, cardiac​ dysrhythmias, and coma. Malignant hypothermia does not cause gastroenteritis or cancer.

A nurse is teaching a client how to perform a breast self-examination (BSE). The nurse should identify which of the following findings as an indication of breast cancer? A. Multiple round masses that are tender and found in both breasts B. A non-tender, hard lump that is palpated in one breast C. Lumps that are mobile and tender on palpation prior to a menstrual cycle D. Bilaterally darkened areoles

B. A non-tender, hard lump that is palpated in one breast

A client is experiencing an elevated temperature due to a viral illness. What should the nurse anticipate being included in this​ client's plan of​ care? Select all that apply. A. Apply warm blankets. B. Administer antipyretic medication. C. Increase fluid intake. D. Administer warm intravenous fluids. E. Keep limbs close to body.

B. Administer antipyretic medication. C. Increase fluid intake

A client has a mass that has been identified by mammogram. Which test may be ordered to further differentiate the mammogram results? A. PRT scan B. Breast biopsy C. Chest x-ray D. Her2 LAB testing

B. Breast biopsy

A client has been receiving treatment for hypothermia. What would indicate that interventions have been​ successful? A. Continues to shiver B. Heart rate of 72 and regular C. Current temperature of​ 95°F D. Blood pressure of​ 88/54 mmHg

B. Heart rate of 72 and regular​ Rationale: Evidence of successful treatment for hypothermia is a heart rate of 72 and regular. The other findings indicate a continued low body temperature.

The nurse is assisting the healthcare provider with a bone marrow aspiration and biopsy on a client who has leukemia. The client also has thrombocytopenia. Upon completing the test, which intervention is a priority for the nurse? A. Dispose of the equipment used, and clean the area properly B. Hold pressure on the wound for approximately 5 minutes C. Make certain the client understands the purpose of the test D. Label and refrigerate the specimen obtained by the physician

B. Hold pressure on the wound for approximately 5 minutes (Venous 5 min, artery 15-20 min)

Which of the following interventions can be performed by the nurse to reduce the risk of bleeding in a patient diagnosed with leukemia (Select all that apply) A. Obtain vital signs every 4 hrs including a rectal temperature B. Instruct patient to avoid forcefully blowing their nose, coughing or sneezing C. Monitor and promptly report abnormal blood levels D. Assess body systems every shift for signs of bleeding

B. Instruct patient to avoid forcefully blowing their nose, coughing or sneezing C. Monitor and promptly report abnormal blood levels D. Assess body systems every shift for signs of bleeding

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. keep the client on bedrest with the affected parts elevated B. Massage frostbite areas to rewarm them water circulation C. Rapidly rewarm affected areas in circulating warm water D. Debride blisters

B. Massage frostbite areas to rewarm them water circulation A nurse should never massage frostbite areas, as this action will further damage necrotic tissue. All other choices are appropriate nursing interventions for a client with frostbite.

A client has just had breast surgery after diagnosis of breast cancer. She had removal of the breast tissue and lymph nodes under the arm but the chest wall muscle remain intact. The nurse explains this type of procedure is called what? A. Radical Mastectomy B. Modified radical Mastectomy C. Simple Mastectomy D. Segmental Mastectomy

B. Modified radical Mastectomy

A hospitalized client with a body temperature of 104°F is entering the flush phase of the fever. Which action by the nurse is appropriate when providing care? A) Restricting fluids. B) Monitoring intake and output. C) Covering the client with warm blankets. D) Providing warmed intravenous fluids

B. Monitoring intake and output. During the flush phase of a fever, the client's body is attempting to adjust the temperature set-point lower. Nursing measures are implemented in order to aid the body in reestablishing a core temperature compatible with normal cellular functioning. The nurse must diligently monitor the client's intake and output to addresses changes in hydration state. Restricting fluids could lead to dehydration and a higher body temperature. Warm blankets and warm intravenous fluids will increase the body's temperature.

The nurse is caring for a client newly admitted with suspected leukemia. The nurse anticipates which of the following tests will be ordered to confirm the diagnosis? (Select all that apply) A. Sedimentation rate B. Red blood cell count C. White blood cell count D. Platelet count

B. RBC C. WBC D. PLATELET COUNT

The nurse is caring for a client with leukemia who is experiencing neutropenia as a result of chemotherapy. Which action should the nurse include in the plan of care for this client? A. Replace hand hygiene with gloves B. Restrict visitors with communicable illnesses C. Insert an indwelling urinary catheter to prevent skin breakdown D. Restrict fluid intake

B. Restrict visitors with communicable illnesses

A client recovering from surgery to place a permanent colostomy as treatment for colon cancer is concerned that her spouse will no longer find her sexually attractive. Which response by the nurse is the most appropriate? A. Would you like me to speak with your husband for you B. Tell me more about the concerns you are having C. I will refer you to a counselor to talk about your concerns D. Do not worry about sex right now. It is more important to focus on recovery

B. Tell me more about the concerns you are having

The nurse is caring for a client with colorectal cancer who is post operative from a transverse colostomy placement. What area of the bowel is involved? A. Ascending B. Transverse C. Descending D. Sigmoid

B. Transverse Colostomies take the name of the portion of the colon from which they are formed. The transverse colon is the area of the bowel involved.

When flushing occurs in a client with a fever, what underlying mechanism to restore normal temperature is occurring? A) Increased metabolism B) Vasodilation C) Insensible water loss D) Increased thyroxine output

B. Vasodilation Flushing is redness of the skin that occurs when blood vessels vasodilate in order to bring more blood flow to the body's surface. This allows the air's cooler temperature to reduce the temperature of the blood flow as heat dissipates through convection

A nurse is preparing a plan of care for a patient who is postoperative following a modified radical mastectomy. Which of the following invasive devices should the nurse expect the patient to have? A. Indwelling urinary catheter B. Wound drains C. Chest tube D. Nasogastric tube

B. Wound drains

A pediatric nurse is caring for a child with acute lymphoblastic leukemia (ALL). When providing education to the child's parents regarding this disease, which topics should the nurse include? Select all that apply. A) ALL is characterized by abnormal proliferation of all bone marrow elements. B) This form of leukemia is the most common type among children and adolescents. C) Most cases of ALL result from the malignant transformation of B cells. D) Malignant lymphocytes are able to effectively maintain immunity. E) The onset of ALL is usually gradual.

BC Acute lymphoblastic leukemia (ALL) is the most common type of leukemia among children and adolescents. Most cases of ALL result from the malignant transformation of B cells. The onset of ALL is usually acute and rapid. Malignant lymphocytes are immature and do not function effectively to maintain immunity. Chronic myeloid leukemia (CML) is characterized by abnormal proliferation of all bone marrow elements

The nurse is listing consequence of malignant hyperthermia Which of the following can be a result of malignant hyperthermia . (SATA). A. Gastroenteritis B. Cardiac dysrhythmias C. Renal-failure D. Coma E. Cancer

BCD Malignant hyperthermia is an inherited disorder that affects tem- peratureregulation.Withthis condition,anindividualexperiences a serious reaction to inhaled anesthetic gases and depolarizing neuromuscular blockers. If not treated, the individual will devel- op renal failure, cardiac dysrhythmias, and coma. Malignant hy- pothermia does not cause gastroenteritis or cancer

While completing a physical examination, the nurse suspects a client has breast cancer. What did the nurse assess in this client? Select all that apply. A) Rash along the inside of the right arm B) Left nipple retraction C) Palpable lump in the upper outer right quadrant D) Scaliness near the right nipple E) Pain when extending the left arm

BCD Manifestations of breast cancer include nipple retraction; a palpable lump, usually in the upper outer quadrant; and scaliness of the skin.

An adult client reports to the nurse an inability to tolerate usual exercise and the feeling of fatigue. The client states that these symptoms have been gradual over time. Which physical assessment findings, along with the client's verbal complaints, would indicate chronic lymphocytic leukemia (CLL)? Select all that apply. A) Joint pain B) Pallor C) Splenomegaly D) Abnormal bleeding E) Edema

BCE The symptoms for CLL are insidious and occur over time, affecting older adults. The client may exhibit splenomegaly, pallor, edema, and lymphadenopathy.

A client is receiving care for an elevated body temperature. Which assessment findings indicate that care has been effective? Select all that apply. A) Urine output of 20 mL/hour B) Moist mucous membranes C) Heart rate of 120 beats per minute D) Good skin turgor E) Blood pressure of 118/68 mmHg

BD Evidence that interventions have been effective for a client with an elevated body temperature includes moist mucous membranes and good skin turgor. Urine output of 20 mL/hour indicates dehydration. Blood pressure of 118/68 mmHg is not an indication of the control of fever. A heart rate of 120 beats per minute could indicate dehydration.

A nurse is caring for a client who has had a double-barrel colostomy. Which is true regarding the proximal stoma? Select all that apply. A) It is also called the mucous fistula. B) It diverts feces to the abdominal wall. C) It expels mucus from the distal colon. D) It is a functional stoma. E) It expels mucus from the proximal colon.

BD When a double-barrel colostomy is performed, two separate stomas are created. The distal colon is not removed, but bypassed. The proximal stoma, which is functional, diverts feces to the abdominal wall. The distal stoma, also called the mucous fistula, expels mucus from the distal colon.

The nurse is caring for a patient who is understanding core rewarming after extreme cold exposure the patient is still hypothermic despite efforts to warm them up. The nurse should ask the patients relatives about a history of which medical condition? A. Hyperthyroidism B. Diabetes C. Hypothyroidism D. Heart disease

C Hypothyroidism Patients who fail to rewarm may have hypothyroidism, and the nurse should ask the patient's relatives about a history of this condition. Medication list, medical history, and surgical scars can also provide information about potential hypothyroidism. Hyperthyroidism, diabetes, and heart disease do not impact a patient's ability to rewarm following hypothermia.

The nurse is preparing to perform a health assessment on an adult client who has a family history of cancer. Which questions should the nurse ask the client to assess for the early warning signs of cancer? Select all that apply. A) "Do you have a cough that is associated with seasonal allergies?" B) "Have you noticed a change in your appetite?" C) "Have you noticed any cuts that have not healed?" D) "Have you had any changes in bowel or bladder habits?" E) "Have you experienced any problems swallowing?"

C) "Have you noticed any cuts that have not healed?" D) "Have you had any changes in bowel or bladder habits?" E) "Have you experienced any problems swallowing?" Nurses should assess all clients, especially those with a history of cancer, for early warning signs of cancer. The early warning signs include change in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, thickening or lump in the breast or elsewhere, indigestion or difficulty swallowing, obvious change in wart or mole, or a nagging cough or hoarseness.

A 31-year-old pregnant client in her second trimester of pregnancy presents in the doctor's office with a fever of 102°F. The client is extremely upset and concerned that her elevated temperature may harm her unborn child. Which statement should the nurse include when explaining the client's risk? A) "Maternal fever is only problematic when it reaches 103° or higher, but temperatures below this level are generally not a concern." B) "Maternal fever is not associated with birth defects; rather, the medication taken to reduce the fever may cause problems." C) "Maternal fever is a concern during pregnancy, but the risk to the child is greatest during the first trimester." D) "Maternal fever is not associated with birth defects, but other types of hyperthermic exposure are associated with them."

C) "Maternal fever is a concern during pregnancy, but the risk to the child is greatest during the first trimester."

What is the primary means of assessing the severity of hyperthermia? A) Core temperature measurement B) Skin temperature measurement C) Clinical presentation of the client D) Client history related to current condition

C) Clinical presentation of the client Clinical presentation of the client should determine the severity of hypothermia, and all clients diagnosed with hypothermia should undergo a complete body survey. Severity of hypothermia should not be determined based on temperature measurement, as methods of measuring temperature and degree of accuracy may differ. History may be useful for determining causative factors, but not severity of condition.

The nurse is caring for a client who presents to the emergency department after a boating accident in which the client nearly drowned. The nurse understands that which type of heat loss resulted in a diagnosis of hypothermia? A) Evaporation B) Insensible water loss C) Convection D) Insensible heat loss

C) Convection Convection is the process of heat transfer through the fluid motion of air or water across the skin. The clients of a boating accident developed hypothermia through convection. Evaporation is the process of converting water to a vapor, and the evaporation of sweat transfers the heat in the sweat to the air. Insensible water loss is unnoticed water loss through evaporation. Insensible heat loss is the loss of heat through evaporation.

A woman has a family history of breast cancer, and genetic testing has revealed a mutation in BRCA2. If this woman develops breast cancer, what is the most likely mechanism for why the cancer developed? A) The cells' ability to accurately translate the RNA was impaired. B) The cells underwent mitosis rather than meiosis. C) The cells' ability to suppress tumor growth was impaired. D) The cells were stimulated to undergo rapid cell division.

C) The cells' ability to suppress tumor growth was impaired. Both BRCA1 and BRCA2 are tumor suppressor genes that help prevent the overstimulation of cell growth.

A client is started on antibiotic therapy for a respiratory infection. Which goal is appropriate for this client? A) The client will have no evidence of sweating. B) The client's mucous membranes will be dry. C) The client's temperature will be within normal limits within 48 to 72 hours of the administration of the antibiotic. D) The client's temperature will approach normal within 60 minutes of the administration of the antibiotic.

C) The client's temperature will be within normal limits within 48 to 72 hours of the administration of the antibiotic.

A client comes into the Emergency Department with a body temperature of​ 103°F. It is a hot and humid​ day, and the client works in a factory with no air conditioning. What should the nurse do to help this​ client?Select all that apply. A. Assess vital signs. B. Use warm blankets. C. Remove or loosen clothing around the neck and chest. D. Apply cool wash cloths to the face and neck E. Restrict fluids F. Draw labs including CBC and blood cultures

C, D Rationale: Until the client has orders​ written, the nurse can apply cool washcloths to the​ client's face and neck to increase comfort and reduce the​ client's body temperature. The nurse can also reduce clothing and skin covering by loosening clothing around the neck and chest. Assessing vital signs and drawing blood is​ important; however, the nurse needs to intervene to help bring the body temperature down. Warm blankets and fluid restriction would keep the temperature elevated rather than helping to decrease it..

The nurse is preparing to perform a health assessment on an adult client who has a family history of cancer. The nurse is aware all of the following are questions to asses for elderly warning signs of cancer with the exception of which? A. "Have you had any changes in bowel or bladder habits?" B. "Have you experienced any problems swallowing?" C. "Do you have a cough that is associated with seasonal allergies?" D. "Have you noticed any cuts that have not healed?"

C. "Do you have a cough that is associated with seasonal allergies?"

The mother of​ preschool-age client tells the nurse that the client has frequent fevers. What should the nurse respond to this​ mother? A. "Your child's immunity is​ compromise" B. ​"This is unusual because common diseases of childhood rarely result in​ fevers."​ C. "Fevers are most frequently seen in children because of developing​ immunity." D. ​"Your child must be around people with​ illnesses."

C. "Fevers are most frequently seen in children because of developing​ immunity." Rationale: The very young and the very old have diminishing​ immunity, which places them at risk for fevers. Fevers are most frequently seen in children because of developing immunity. The nurse has no way of knowing if the​ client's immunity is compromised. The child may or may not be around people with illnesses. Common diseases of childhood frequently result in fevers.

A 31-year-old pregnant client in her second trimester of pregnancy presents in the doctor's office with a fever of 102°F. The client is extremely upset and concerned that her elevated temperature may harm her unborn child. Which statement should the nurse include when explaining the client's risk? A) "Maternal fever is only problematic when it reaches 103° or higher, but temperatures below this level are generally not a concern." B) "Maternal fever is not associated with birth defects; rather, the medication taken to reduce the fever may cause problems." C) "Maternal fever is a concern during pregnancy, but the risk to the child is greatest during the first trimester." D) "Maternal fever is not associated with birth defects, but other types of hyperthermic exposure are associated with them."

C. "Maternal fever is a concern during pregnancy, but the risk to the child is greatest during the first trimester." Hyperthermic exposure and maternal fever in the first trimester of pregnancy have been associated with congenital defects. Studies indicate that it is the fever itself—not medication or maternal illness—that is associated with such defects. A temperature of 101.3° or greater is considered a fever.

The nurse is assessing several children with polyps in the colon and rectum. Which child is at highest risk of developing colorectal cancer in adulthood? A) A 4-year-old with isolated juvenile polyps B) A 6-month-old with diffuse juvenile polyposis of infancy C) A 12-year-old with juvenile polyposis coli D) A 7-year-old with adenomatous polyps

C. A 12-year-old with juvenile polyposis coli Children who develop juvenile polyposis or juvenile polyposis coli have an increased risk of developing colorectal cancer in adulthood by as much as 50%. Adenomatous polyps also increase the risk for malignancy as adults, but this risk is not as high as 50%. Isolated juvenile polyps lack malignant potential. Diffuse juvenile polyposis of infancy is almost always fatal, so the client is not likely to reach adulthood.

The nurse is caring for patients. Which patient should the nurse assess as having the highest risk for developing hyperthermia A. A 60- year-old adult with congestive heart failure B. A 20-year-old with Asthma exacerbation C.A 4- month old child with respiratory virus D. A 45- year old adult with uncontrolled diabetes mellitus

C. A 4- month old child with respiratory virus

The nurse is caring for a client who is experiencing hyperthermia. Which intervention is appropriate for this​ client? A. Applying warm blankets B. Covering the scalp with a hat C. Administering a prescribed antipyretic medication D. Keeping limbs close to the body

C. Administering a prescribed antipyretic medication

The nurse is caring for a client admitted with minor burns and elevated body temperature after being in a house fire. What should be included in this​ client's plan of care to address the elevated body​ temperature? Select all that apply. A. Keeping the room temperature warm B. Restricting fluids C. Lowering room temperature D. Encouraging fluids E. Providing blankets

C. Lowering room temperature D. Encouraging fluids

Which type of body temperature changes in response to the environment? A. Core B. Metabolic C. Surface D. Physiologic

C. Surface Surface temperature changes in response to the environment. Core temperature remains constant and stays within a specific range. Metabolic and physiologic are not types of body temperature

A client prescribed tamoxifen (Nolvadex) for breast cancer treatment asks the nurse how Medication works. What is the best response by the nurse? A. "Tamoxifen works by inhibiting the cellular mitosis of breast cancer." B. "Tamoxifen works by binding the DNA of breast cancer cells." C. Tamoxifen works by blocking estrogen receptors on breast tissue D. Tamoxifen works by inhibiting the metabolism of breast cancer cells

C. Tamoxifen works by blocking estrogen receptors on breast tissue

Which hormone is responsible for epinephrine release and thus chemical​ thermogenesis? A. Aldosterone B. Progesterone C. Thyroxine D. Norepinephrine

C. Thyroxine

A client comes into the emergency department complaining of the inability to feel the hands and feet after waiting for 2 hours for transportation in​ 20°F weather. What should the nurse do to help this​ client? A. Warm the hands and feet in tepid water for 2 hours. B. Rub and massage the hands and feet. C. Warm the hands and feet in​ 104°F water for 20 to 30 minutes. D. Provide an antipyreti

C. Warm the hands and feet in​ 104°F water for 20 to 30 minutes. Rationale: The​ client's inability to feel his hands and feet after spending 2 hours in​ 20°F weather would indicate the client is experiencing frostbite. Rapid thawing decreases tissue necrosis and should be done by warming the hands and feet in​ 104°F water for 20 to 30 minutes. The hands and feet should not be rubbed. Tepid water will not rapidly warm the hands and feet. Antipyretics would be indicated for a fever.

A patient is diagnosed with metaplasia of cancer tissue. which should the nurse consider as being the first course of treatment of this patient? A. Chemotherapy B. antibiotictherapy C. identification and removal of the irritant causing the metaplasia D. Radiation therapy

C. identification and removal of the irritant causing the metaplasia

An unresponsive patient is brought into the emergency department after being found in cold intervention by the nurse? A. Apply warming blankets B. Assessing the patient's skin for frostbite C. Assessing respiratory status, oxygenation, and perfusion D. Hanging warmed intravenous fluids

C.Assessing respiratory status, oxygenation, and perfusion The priority intervention by the nurse is to assess respiratory status and how effective the patient is oxygenating and perfusing. If the patient is not breathing or does not have a heartbeat, the nurse must implement cardiopulmonary resuscitation (CPR) and initiate the code team as per hospital policy. Assessing for frostbite is an important intervention but not until it is determined that the patient is breathing appropriately. Application of warming blankets or instillation of warmed intravenous fluids may be ordered by the healthcare provider but are not the priority for the nurse.

The nurse is caring for a 6 year old who has been hospitalized for a week with a fever of unknown origin. During this morning's vital signs evaluation, the nurse notes that the child has a temperature of 37.5*c (99.5 *F). which is the nurse's priority intervention? A. Administering antipyretics as order B. placing ice packs in the armpits and groin C. Informing the healthcare provider D. Documenting the finding as normal

D Documenting the finding as normal A temperature of 37.5°C (99.5°F) is considered to be a low-grade fever. The nurse only needs to document the finding and continue to monitor the child's temperature. There is no need to inform the healthcare provider, administer antipyretics, or place ice packs in the child's armpits or groin.

A nursing student is discussing thermoregulation with fellow students. Which statement about thermoregulation does the student recognize as being true? A) "Core temperature varies widely depending on the outside environment." B) "The body's surface temperature remains relatively constant." C) "Chemical thermogenesis occurs with the increase of cortisol." D) "All muscle activity, regardless of location, produces heat."

D) "All muscle activity, regardless of location, produces heat." All muscle activity, regardless of location, produces heat. Core temperature remains relatively constant, whereas the body's surface temperature varies widely depending on the outside environment. Chemical thermogenesis occurs with increased output of thyroxine, not cortisol.

A nurse working in a gerontologist's office is reviewing the files of patients who have appointments today. Of these patients, which one should the nurse identify as having the lowest risk for developing hypothermia? A) An 80-year-old client with hypothyroidism and a lengthy medication regimen B) A 69-year-old client with type 2 diabetes mellitus and peripheral neuropathy C) A 75-year-old client with decreased subcutaneous fat and several dietary restrictions D) A 78-year-old client who regularly walks and does strength training with small hand weights

D) A 78-year-old client who regularly walks and does strength training with small hand weights

The nurse is caring for a client admitted with minor burns and elevated body temperature after being in a house fire. What should be included in this client's plan of care?Select all that apply. A) Providing blankets B) Keeping the room temperature warm C) Restricting fluids D) Encouraging fluids E) Lowering room temperature

D) Encouraging fluids E) Lowering room temperature

On a hot, humid day, a client presents with a body temp. of 105.6F, dry and flushed skin, vomiting, low BP, and muscle cramps. Which type of injury should the nurse suspect based on the manifestations? A. Normothermia B. Hypothermia C. Malignant hyperthermia D. Heat Stroke

D) Heat Stroke RA: 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, 32-​35°C​(89.6-​95°F);​moderate, 28-​32°C​(82.4-​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

The nurse is educating a family who is planning an ice fishing trip on ways to prevent hypothermia. Which recommendation by the nurse is appropriate? A) All family members should wear skid-proof footwear. B) If someone becomes hypothermic, sponge tepid water onto any exposed skin. C) All family members should wear light rain jackets. D) If someone becomes hypothermic, remove any wet clothing, wrap the person in blankets, and have the person drink a warm liquid.

D) If someone becomes hypothermic, remove any wet clothing, wrap the person in blankets, and have the person drink a warm liquid. First aid for hypothermia includes moving the person to a dry area, removing wet clothing, protecting the person from further environmental exposure, wrapping the person in dry blankets, dressing the person in warm and dry clothing, and having the person drink a warm, high-calorie liquid. Skid-proof footwear and light rain jackets will not prevent hypothermia. Tepid water is used in cases of hyperthermia, not hypothermia.

A nurse is caring for a client with a fever who is experiencing tachypnea. Which is true regarding this client's condition? A) The decrease in prostaglandin production causes the respiratory rate to increase. B) Although it sometimes occurs, an increased respiratory rate is not a common reaction to fever. C) One degree of temperature elevation causes an increase in respiratory rate by two breaths per minute. D) One degree of temperature elevation causes an increase in respiratory rate by four breaths per minute.

D) One degree of temperature elevation causes an increase in respiratory rate by four breaths per minute.

The nurse is teaching a class to prospective parents about the role that deoxyribonucleic acid (DNA) Place in the development of the human fetus. Which statement made by the parents indicates understanding of the teaching? A. "DNA is attached to the endoplasmic reticulum" B. "DNA is outside the nucleus of the cell" C. "DNA is used to form ribozymes" D. "DNA molecules are made up of genes"

D. "DNA molecules are made up of genes"

The nurse working in the pediatric intensive care unit (PICU) is caring for a child with leukemia. what is the most common type of leukemia in children? A. chronic myeloid(myelogenous) leukemia B. Chroniclymphocyticleukemia C. acute myeloid (myeloblastic) leukemia D. Acute lymphocytic (lymphoblastic) leukemia

D. Acute lymphocytic (lymphoblastic) leukemia

The nurse is providing care to a client who has a body temperature of 34.4 (94 F) an irregular heart rate and low blood pressure which is priority intervention for this client. A. Elevate the head of the bed B. provide a heating pad to the client's lower back C. elevate the client's leg D. Administer warmed intravenous fluid

D. Administer warmed intravenous fluids. ​Rationale: The client is mildly hypothermic with symptoms of an irregular heartbeat and low blood pressure. Warmed intravenous fluids would be beneficial for this client. Elevating the legs or the head of the bed will not help with the​ client's hypothermia. A heating pad to the lower back is not indicated in the treatment of hypothermia

Treatment options for a client diagnosed with acute myeloid leukemia (AML) are being discussed. The nurse informs the client that the most likely treatment will include complete and sustained replacement of their blood cell lines (WBCs, RBCs, and platelets) with cells derived from donor stem cells. Which treatment is the nurse referring to? A. Radiation B. Allogeneic bone marrow transplant (BMT) C. Autologous bone marrow transplant (BMT) D. Allogeneic stem cell transplant (SCT)

D. Allogeneic stem cell transplant (SCT)

The nurse is providing care to a client who is experiencing an elevated body temperature. Which class of medication does the nurse anticipate will be prescribed for this​ client? A. Antihypertensive B. Antiemetic C. Anticholinergic D. Antipyretic

D. Antipyretic

A nurse is working in the labor and delivery unit. What statement does the nurse understand is true regarding newborn thermogenesis? A. Shivering occurs when receptors perceive a drop in the environmental temperature and transmit sensations to stimulate sympathetic nervous system B. Shivering thermogenesis uses the newborns stores of brown fat to provide heat C. The extra muscular activity by the infant in cold stress produces a large amount of body heat D. Brown fat produces heat generation, and heat transfer to the peripheral circulation.

D. Brown fat produces heat generation, and heat transfer to the peripheral circulation. First appears at 26 to 28 weeks and continues till 3 to 5 weeks after birth, unless depleted by cold stress. Brown fat is deposited in midscapular, around neck, axillas, deeper placement around trachea, esophagous, abdominal aorta, kidneys, and adrenal glands. It has dark color due to renrished blood supply, dense cellular content, and nerve endings. It provides rapid metabolism, heat generation and heat transfer to the peripheral circulation. It increases the speed with which brown cells are metabolized to produce heat but cause increased oxygen consumption and caloric output in the already compromised infant.

A client is admitted with the diagnosis of fever of unknown origin. Which diagnostic test does the nurse anticipate for this​ client? A. Bone scan B. Glucose tolerance test C. CT scan of the abdomen D. Complete blood count

D. CBC

A patient tells the nurse, "My father had a sever fever from the anesthesia when he had surgery." which diagnosis test should the nurse anticipate that health care provide will order? A. Complete blood count (CBC) B. Computed tomography (CT scan) C. Magnetic resonance imaging (MRI) D. Caffeine halothane contracture test (muscle biopsy)

D. Caffeine halothane contracture test The nurse would anticipate that the healthcare provider would order a caffeine halothane contracture test or genetic testing to confirm the risk for malignant hyperthermia. It is important to determine whether the patient is at risk prior to surgery so the proper precautions can be taken.

All the following are responsible for heat production in the body with EXCEPTION of which one? A. Muscular Activity (shivering) B. Basal Metabolic rate (BMR) C. Thyroxine and epinephrine D. Evaporation (vaporization)

D. Evaporation

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. Metabolism C. Conduction D. Evaporation

D. Evaporation RA: 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.

In the​ past, a college campus in a cold climate has had multiple students require treatment for mild hypothermia during the winter months. Which method would be most effective for the campus nurse to use to promote healthy thermoregulation on this​ campus? A. Sell inexpensive pocket handwarmers in the campus bookstore. B. Put up posters encouraging students to wear hats and mittens. C. Send emails telling students that alcohol consumption prevents hypothermia. D. Show a video about the harmful effects of hypothermia due to exposure.

D. Show a video about the harmful effects of hypothermia due to exposure.

During an​ assessment, the nurse notes that a client who was a victim of an industrial accident has a mildly elevated body temperature. When discussing the​ client's increased​ temperature, which will the nurse attribute it​ to? A. Diet B. Infection C. Exercise D. Stress

D. Stress

The nurse is caring for an older adult client who was admitted with pneumonia. The​ client's vital signs​ are: P​ 84, R​ 22, BP​ 118/74, T​ (oral) 98.3degreesF. The client asks the nurse to explain how she can have an infection without having a fever. How should the nurse​ respond? A. The client was likely misdiagnosed and does not have an infection. B. The cool temperature of the hospital room helps prevent fevers. C. The loss of body heat associated with pneumonia reduces the risk of fever. D. The​ body's ability to respond to changes in temperature declines with age.

D. The​ body's ability to respond to changes in temperature declines with age.

The nurse needs to assess the body temperature of a client who has just smoked a cigarette and consumed hot coffee. Which temperature assessment method should the nurse​ use? A. Temporal artery B. Rectal C. Axillary D. Tympanic

D. Tympanic

The nurse is conducting a presentation on colon cancer. The nurse educates members of the audience on manifestations of colorectal cancer. Which response by an audience member indicates a need for further teaching? A. Changes in bowl habits B. Unexplained weight loss C. Rectal bleeding D. Visual changes

D. Visual changes

The nurse is assessing an older adult client recently diagnosed with colorectal cancer. what information is important for the nurse to ask for when completing the geriatric assessment? A. the client's food diary for the past month B. the names, addresses, and birth dates of all the client's children C. whether the client has ever had a gastrointestinal disorder that causes diarrhea D. a complete list of all medications and supplements the client is currently taking

D. a complete list of all medications and supplements the client is currently taking

A client is receiving chemotherapy for acute lymphocytic leukemia. while providing care for this client, which clinical manifestations would indicate tumor lysis syndrome? A. upper extremity edema and dizziness B. thrombocytopenia and Nosebleed C. respiratory distress and tachypnea D. cardiac arrhythmia and renal failure

D. cardiac arrhythmia and renal failure

A client presents in the emergency department with a core body temperature of 88.8degreesF. The nurse understands that this temperature indicates this patient is A. normothermic. B. febrile. C. mildly hyperthermic. D. moderately hypothermic.

D. moderately hypothermic.

The nurse is planning care for a client with acute myeloid leukemia (AML). which diagnosis is a priority for this client to minimize the risk of complications associated with AML? A. fluid volume access B. ineffectivethermoregulation C. Imbalanced nutrition, less than body requirements D. risk for infection

D. risk for infection