Thermoregulation NCLEX style Questions
Which is a noninvasive method that the nurse uses to assess a client's temperature? (Select all that apply.) A. Axillary B. Rectal C. Oral D. Temporal artery E. Tympanic membrane
A. Axillary D. Temporal Artery
The nurse is listing consequences of malignant hyperthermia. Which consequences should be included? (select all that apply) A. Disseminated intravascular coagulation B. Renal failure C. Cardiac dysrhythmias D. Gastroenteritis E. Pulmonary edema
A. Disseminated intravascular coagulation B. Renal failure C. Cardiac dysrhythmias E. Pulmonary edema
The nurse is preparing a presentation to parents about vehicle safety and heat-related injuries. Which important teaching point should be included? A. Keep important articles in the backseat to ensure checking the area before leaving the vehicle. B. Store car keys in a visible place and within the children's reach in case of an emergency. C. Leave a child alone in the car only if the outside temperature is below 80degrees°F. D. Stay with a child in the car for up to 10 minutes with the windows cracked open.
A. Keep important articles in the backseat to ensure checking the area before leaving the vehicle Rationale: Estimates indicate that numerous children die from vehicle hyperthermia, or sustain heat exhaustion, heat stroke, and thermal burn after being left in vehicles on warm days. One way of ensuring that such incidents do not happen is to teach caregivers to place something important, such as their wallet or cell phone, in the backseat of the car. This will ensure that they check the backseat before leaving the vehicle. Advise them to always look before they lock, when not in use. According to reports and findings, leaving a child in a car with a cracked window for even a short amount of time, holds the potential for lethal consequences. Children should never be left unattended or around vehicles. Though it is a good practice to keep car keys in a visible place, ensure that they are out of reach of children.
The nurse is planning to assess a 4-year-old child to help determine the cause of the child's fever. Which body system is a priority to assess? (Select all that apply.) A. Urinary B. Musculoskeletal C. Respiratory D. Gastrointestinal E. Neurologic
A. Urinary C. Respiratory D. Gastrointestinal Rationale: Infections of the urinary, respiratory, and gastrointestinal systems are the most common reason for a fever in this age range. The neurologic and musculoskeletal systems are not common systems for infections in children.
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
The nurse is evaluating teaching provided to the parents of 2-year-old twins regarding temperature measurement devices in the home. Which observation indicates that teaching has been effective? (Select all that apply.) A. Separate mercury glass thermometers are available for each child. B. There is no evidence of a temperature-measuring device in the home. C. Mercury glass thermometers are removed from the home. D. An electronic thermometer with disposable covers is available for use. E. Pad and pencil are placed next to the temperature-measuring device.
C. Mercury glass thermometers are removed from the home D. an electronic thermometer with disposable covers is available for use E. Pad and pencil are placed next to the thermometer measuring device
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.
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 type of body temperature changes in response to the environment? A. core B. metabolic C. surface D. physiologic
C. Surface
The nurse is preparing to use the tympanic membrane to measure the temperature of a 4-year-old child. Which approach should the nurse take when completing this measurement? A. Pull the earlobe back and up. B. Pull the pinna back and down. C. Pull the pinna back and up. D. Pull the earlobe back and down.
C. pull the pinna back and up Rationale: The pinna is pulled straight back and upward when taking temperature in children over 3 years of age. To measure temperature using the tympanic membrane in an infant, the pinna is pulled straight back and slightly downward. The earlobe is not manipulated to measure temperature using the tympanic membrane.
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.
