Thermoregulation NCO

While caring for a client on antidepressant therapy, the nurse observes hyperthermia and seizures. Upon a further assessment, the nurse finds that the client's heart rate is 200 beats per minute. Which medication might be responsible for the condition? 1. Sertraline 2. Asenapine 3. Risperidone 4. Fluphenazine

1 A heart rate of 200 beats per minute indicates cardiac dysrhythmias. Hyperthermia, seizures, and cardiac dysrhythmias in a client on antidepressant therapy indicate serotonin syndrome. Serotonin syndrome is an adverse effect of selective serotonin inhibitors such as sertraline. Asenapine, risperidone, and fluphenazine are antipsychotics that may cause drowsiness, neuroleptic malignant syndrome, extrapyramidal symptoms, and tardive dyskinesia as adverse effects.

A client gives birth to a full-term male with an 8/9 Apgar score. What should the immediate nursing care of this newborn include? 1. Assessing respirations, keeping him warm, and identifying him 2. Applying an antibiotic to the eyes, administering vitamin K, and bathing him 3. Aspirating the oropharynx, rushing him to the nursery, and stimulating him often 4. Weighing him, placing him in a crib, and waiting until the mother is ready to hold him

1 Establishing a patent airway, diminishing cold stress, and identifying the newborn are the priorities. Application of eye prophylaxis and administration of vitamin K are often delayed to allow the parents to bond with the infant; a bath at this time will increase the risk of cold stress. Aspirating the oropharynx, rushing him to the nursery, and stimulating him frequently are measures appropriate for a compromised newborn; an 8/9 Apgar score is indicative of a healthy newborn. Weighing him, placing him in a crib, and waiting until the mother is ready to hold him are not the priority care for a newborn.

A woman reports weight gain and hot flashes. The client is also found to have low estrogen levels. Which drug may be prescribed to alleviate hot flashes? 1. Estradiol 2. Raloxifene 3. Clomiphene 4. Dinoprostone

1 Estradiol is a form of estrogen that helps to alleviate hot flashes by increasing estrogen levels. Raloxifene may cause or increase hot flashes. Clomiphene may cause conception in infertile women and is not advised. Dinoprostone may cause a termination of pregnancy.

An older adult with a history of diabetes reports giddiness, excessive thirst, and nausea. During an assessment, the nurse notices the client's body temperature as 113° F. Which condition does the nurse suspect in the client? 1. Heat stroke 2. Heat exhaustion 3. Accidental hypothermia 4. Malignant hyperthermia

1 Older adults are more at a risk of heat stroke. Symptoms of heat stroke include giddiness, excessive thirst, nausea, and increased body temperature. Heat exhaustion is indicated by a fluid volume deficient. Heat exhaustion occurs when profuse diaphoresis results in excess water and electrolyte loss. Accidental hypothermia usually develops gradually and goes unnoticed for several hours. When the skin temperature drops below 95° F, the client suffers from uncontrolled shivering, memory loss, depression, and poor judgment. Malignant hyperthermia is an adverse effect of inhalational anesthesia that is indicated by a sudden rise in body temperature in intraoperative or postoperative clients.

A nurse sees another health team member cover an infant with a blanket to prevent heat loss. What heat loss mechanism is being minimized by this action? 1. Radiation 2. Conduction 3. Active transport 4. Fluid vaporization

1 Radiation, or the transfer of heat from a warm object to the atmosphere, is prevented by covering the child with a blanket. Reducing body surface area (e.g., flexing all extremities in toward the body) also limits heat loss through radiation. Conduction is the transfer of heat from one molecule to another with contact between the two. Active transport is not related to loss of heat; this is a process that moves ions or molecules across a cell membrane against a concentration gradient. Vaporization is the conversion of liquid or solid into a vapor; it occurs when a person is perspiring. STUDY TIP: A word of warning: do not expect to achieve the maximum benefits of this review tool by cramming a few days before the examination. It doesn't work! Instead, organize planned study sessions in an environment that you find relaxing, free of stress, and supportive of the learning process.

The nurse who works in a birthing unit understands that newborns may have impaired thermoregulation. Which nursing interventions may help prevent heat loss in the newborns? Select all that apply. 1. The nurse keeps the newborn covered in warm blankets. 2. The nurse keeps the newborn under the radiant warmer. 3. The nurse places the newborn on the mother's abdomen. 4. The nurse measures the newborn's temperature regularly. 5. The nurse encourages the mother to feed the newborn well to maintain the fluid balance.

1 2 3 Newborns have impaired thermoregulation due to immaturity of the body systems. Therefore, the nurse performs interventions to prevent heat loss in the newborn. Covering the newborn with warm blankets helps to prevent heat loss. The nurse keeps the newborn under the radiant warmer to help maintain the body temperature. Placing the newborn on the mother's abdomen helps to promote warmth through skin-to-skin contact. Regular measurement of temperature may help in assessing any significant change; however, it may not help prevent heat loss. Ensuring that the newborn is fed well does not help to prevent heat loss.

A nurse assesses the vital signs of a 50-year-old female client and documents the results. Which of the following are considered within normal range for this client? Select all that apply. 1. Oral temperature of 98.2° F (36.8° C) 2. Apical pulse of 88 beats per minute and regular 3. Respiratory rate of 30 per minute 4. Blood pressure of 116/78 mm Hg while in a sitting position 5. Oxygen saturation of 92%

1 2 4 The client's temperature, pulse, and blood pressure are within normal ranges for a 50-year-old female. The client's respirations are mildly elevated, and the oxygen saturation level is below normal. A normal respiratory rate for a female client in this age group would be 12 to 20 per minute, and oxygen saturation level should be 95%.

Neonates have difficulty maintaining their body temperature; however, their bodies have several mechanisms to help them do so. Which ones should a nurse remember when caring for the newborn? Select all that apply. 1. Flexed fetal position 2. Hepatic insulin stores 3. Brown fat metabolism 4. Peripheral vasoconstriction 5. Parasympathetic nervous system

1 3 4 Full-term neonates maintain a flexed fetal position, which conserves heat. Deposition of brown fat begins at 28 weeks' gestation and continues for the rest of the pregnancy; when the newborn's body becomes cool, the sympathetic nervous system stimulates the breakdown of brown fat, which releases heat as a by-product. Peripheral vasoconstriction helps conserve heat by keeping the central core warm and preventing heat from dissipating. Insulin is not stored in the liver and is not involved with maintenance of neonatal body temperature. The sympathetic, not parasympathetic, nervous system is involved in thermoregulation. Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

A nurse needs to use an electronic infrared thermometer to measure the temperature of the tympanic membrane of a 4-year-old child. What steps does the nurse need to take? Select all that apply. 1. Pull the pinna up and out. 2. Pull the pinna backward, up, and out. 3. Avoid applying pressure to the ejection button. 4. Obtain temperature from patient's right ear if nurse is right-handed. 5. Point covered probe toward midpoint between eyebrow and side burns.

1 3 4 The nurse should pull the pinna up and out for a child of 4 years of age. The nurse should be careful not to apply pressure to the ejection button. If the nurse is right-handed, the temperature is measured from the child's right ear. When obtaining an adult's temperature, the nurse should pull the pinna backward, up, and out to measure body temperature. The nurse should point the covered probe toward midpoint between eyebrow and side burns for measuring body temperature in children 3 years and younger.

A nurse is assessing a client with hypothyroidism. Which clinical manifestations should the nurse expect the client to exhibit? Select all that apply. 1. Cool skin 2. Photophobia 3. Constipation 4. Periorbital edema 5. Decreased appetite

1 3 4 5 Cool skin is related to the decreased metabolic rate associated with insufficient thyroid hormone. Constipation results from a decrease in peristalsis related to the reduction in the metabolic rate associated with hypothyroidism. Periorbital and facial edemas are caused by changes that cause myxedema and third-space fluid effusion seen in hypothyroidism. Decreased appetite is related to metabolic and gastrointestinal manifestations of the hypothyroidism. Photophobia is associated with exophthalmos that occurs with hyperthyroidism.

The nurse is assessing a client with hyperthyroidism. Which signs and symptoms might the nurse identify when assessing the client? Select all that apply. 1. Amenorrhea 2. Hypotension 3. Facial edema 4. Flushed appearance 5. Short attention span

1 4 5 Amenorrhea is due to hypothalamic or pituitary disturbances associated with hyperthyroidism. The skin is warm and flushed because of a hyperdynamic circulatory state. A short attention span is related to altered cerebral metabolism from excess thyroid hormones. Hypertension is associated with hyperthyroidism; hypotension is associated with hypothyroidism. Facial edema is not related to hyperthyroidism. Hypothyroidism is associated with decreased renal blood flow that results in fluid retention (e.g., peripheral and facial edema).

The nurse tells a client undergoing diuretic therapy to avoid working in the garden on hot summer days. What condition is the nurse trying to prevent in this client? 1. Frostbite 2. Heatstroke 3. Hypothermia 4. Hyperthermia

2 Clients undergoing diuretic therapy are at risk of heatstroke when exposed to temperatures higher than 40° C. Frostbite occurs when the body is exposed to ice-cold temperatures. Hypothermia is a condition in which the skin temperature drops below 36° C. Hyperthermia occurs when the body is exposed to temperatures higher than 38.5° C.

The nurse expects a client with an elevated temperature to exhibit what indicators of pyrexia? Select all that apply. 1. Dyspnea 2. Flushed face 3. Precordial pain 4. Increased pulse rate 5. Increased blood pressure

2 4 Increased body heat dilates blood vessels, causing a flushed face. The pulse rate increases to meet increased tissue demands for oxygen in the febrile state. Fever may not cause difficult breathing. Pain is not related to fever. Blood pressure is not expected to increase with fever. Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

A client is taking an antithyroid medication for hyperthyroidism. The nurse provides education about serious health problems that may develop if the medication is not effective and tachycardia continues. The nurse instructs the client to seek medical attention immediately if any of the problems occur. Which should be included in the teaching? Select all that apply. 1. Diaphoresis 2. Weight gain 3. Flushed skin 4. Nervousness 5. Pedal edema

2 5 Weight gain is a sign of heart failure, which may develop with the persistent tachycardia that is present with hyperthyroidism; this should be reported to the health care provider immediately. Pedal edema is a sign of heart failure, which may develop with the persistent tachycardia that is present with hyperthyroidism; this should be reported to the health care provider immediately. Diaphoresis, flushed skin, and nervousness are expected to occur with hyperthyroidism and need not be reported immediately.

On the day after surgery for insertion of a ventriculoperitoneal shunt to treat hydrocephalus, an infant's temperature increases to 103.0° F (39.4° C). The nurse immediately notifies the practitioner. What is the next nursing action? 1. Covering the infant with a bath blanket 2. Sponging the infant with tepid alcohol 3. Removing excess clothing from the infant 4. Reassessing the infant's temperature in several hours

3 After the initial safety measures and notification of the practitioner have been addressed, excess clothing, which prevents heat loss, should be removed. Covering the infant will increase the temperature because heat loss will be reduced. Alcohol should never be used for infants or children; it causes severe chilling, which can lead to increased metabolic activity and a higher temperature. This high fever requires more frequent readings, usually at least every hour.

A client's urine specific gravity is being measured. For which condition should the nurse conduct a focused assessment when a client's specific gravity is increased? 1. Polyuria 2. Fluid overload 3. Low-grade fever 4. Diabetes insipidus

3 An elevated temperature can lead to dehydration and an increased urine specific gravity. When there is edema or fluid overload, the accumulating body fluid will cause a decrease in the specific gravity of the urine. A client with diabetes insipidus excretes a large amount of dilute urine; dilute urine will have a decreased specific gravity. Polyuria is excretion of large amounts of urine, making the specific gravity low.

A nurse is planning care for a toddler who has ingested aspirin. What assessment warrants close monitoring because an increase can result in further complications? 1. Blood pressure 2. Abdominal girth 3. Body temperature 4. Serum glucose level

3 Hyperpyrexia (increased temperature) is a manifestation of acute aspirin poisoning; this leads to increased oxygen consumption and heat loss. Blood pressure is not directly affected by aspirin ingestion. Ascites does not occur as a result of aspirin ingestion; it may occur if liver failure develops. Aspirin ingestion does not affect the serum glucose level.

The nurse is assessing the body temperature of four febrile clients over 4 days. Which client is suffering from remittent fever? 1. Client A: 100, 100.4, 100.6, 100.8 2. Client B: 102, 98.5, 103, 99 3. Client C: 103, 101, 104, 102 4. Client D: 102, 98.5, 99.9, 103

3 In remittent fever, body temperature spikes and falls without a return to normal temperature levels. In client C, the temperature for 4 days is febrile with fluctuations, and the temperature does not return to normal. Client A has sustained fever, with a constant body temperature continuously above 38° C (100.4° F) that has little fluctuation. Client B has intermittent fever, in which the fever spikes interspersed with normal temperature levels. Client D has relapsing fever, which has periods of febrile episodes and periods with acceptable temperature values, often for longer than 24 hours. Test-Taking Tip: Chart/exhibit items present a situation and ask a question. A variety of objective and subjective information is presented about the client in formats such as the medical record (e.g., laboratory test results, results of diagnostic procedures, progress notes, health care provider orders, medication administration record, health history), physical assessment data, and assistant/patient interactions. After analyzing the information presented, the test taker answers the question. These questions usually reflect the analyzing level of cognitive thinking.

Two days after a myocardial infarction, a client has a temperature of 100.2° F (37.9° C). What should the nurse do first? 1. Auscultate the chest for diminished breath sounds. 2. Encourage coughing and deep breathing every hour. 3. Record the temperature reading and continue to monitor it. 4. Suspect an infection and notify the healthcare provider immediately.

3 Myocardial necrosis causes a rise in body temperature within the first 24 hours after a myocardial infarction. This increase in temperature gradually returns to the usual range for an adult after several days. A temperature of 100.2° F (37.9° C) is an expected response to myocardial necrosis, not a respiratory infection. Auscultating lung sounds and encouraging coughing and deep breathing are not necessary for the temperature elevation. A temperature of 100.2° F (37.9° C) is an expected response and is not an emergency requiring notification of the primary healthcare provider.

The nurse cares for an unconscious client who underwent head surgery. Which site would be best used to monitor body temperature? 1. Skin 2. Oral 3. Axilla 4. Rectal

4 Although the oral route is the most common route for monitoring body temperature, clients who are unconscious should have their temperatures monitored rectally. Skin temperature may be impaired due to diaphoresis; this measurement may not reliable. The axilla temperature may underestimate the core temperature.

A client has a fever spike that is combined with normal temperature levels. The client's body temperature returns to a normal body temperature at least once a day. Which type of fever can be assessed in the client? 1. Sustained 2. Relapsing 3. Remittent 4. Intermittent

4 An intermittent fever is characterized by fever spikes interspersed with normal temperatures. In this type of fever, the body temperature returns to normal at least once in 24 hours. In the case of sustained fever, there is a constant body temperature greater than 38ºC. In relapsing fever, there is an occurrence of periods of febrile episodes with acceptable temperature values. In remittent fever, the body temperature increases and decreases without returning to normal body temperature levels.

The nurse is caring for a client with a temperature of 104.5 degrees Fahrenheit (40.3 degrees Celsius). The nurse applies a cooling blanket and administers an antipyretic medication. The nurse explains that the rationale for these interventions is to do what? 1. Promote equalization of osmotic pressures 2. Prevent hypoxia associated with diaphoresis 3. Promote integrity of intracerebral neurons 4. Reduce brain metabolism and limit hypoxia

4 Cooling blankets and antipyretic medications can induce hypothermia, thus decreasing brain metabolism. This in turn makes the brain less vulnerable by decreasing the need for oxygen. The integrity of intracerebral neurons and osmotic pressure equalization depend on an adequate supply of oxygen, carbon dioxide, and glucose, and may occur as a result of decreased cerebral metabolism and hypoxia. Diaphoresis does not cause hypoxia. Antipyretic medications may cause diaphoresis as vasodilation occurs. Test-Taking Tip: Answer the question that is asked. Read the situation and the question carefully, looking for key words or phrases. Do not read anything into the question or apply what you did in a similar situation during one of your clinical experiences. Think of each question as being an ideal, yet realistic, situation.

Immediately after birth, a newborn is dried before being placed in skin-to-skin contact with the mother. What type of heat loss does this intervention prevent? 1. Radiation 2. Convection 3. Conduction 4. Evaporation

4 Evaporative heat loss is a result of the conversion of moisture into vapor, which is avoided when the newborn is dried. Radiation is the loss of heat to colder solid surfaces that are not in direct contact. Convective heat loss is a result of contact of the exposed skin with cooler surrounding air currents. Conductive heat loss is a result of direct skin contact with a cold solid object.

On admission to the nursery a newborn is found to be experiencing cold stress. What is the nurse's immediate goal at this time? 1. Minimize shivering 2. Prevent hyperglycemia 3. Limit oxygen consumption 4. Prevent metabolism of fat stores

4 If the newborn is cold there is increased brown fat metabolism (nonshivering thermogenesis), which increases levels of fatty acids in the blood, predisposing the infant to acidosis. Newborns do not shiver. Hypoglycemia, not hyperglycemia, may occur because the newborn's glycogen reserves are depleted rapidly when under stress. Although oxygen consumption increases during cold stress, limiting oxygen consumption is not the priority; increased fat metabolism is more serious.

A client with severe preeclampsia develops eclampsia. After the seizure, the client has a temperature of 102° F (38.9° C). What does the nurse suspect as the cause of the elevated temperature? 1. Excessive muscular activity 2. Development of a systemic infection 3. Dehydration caused by rapid fluid loss 4. Irregularity in the cerebral thermal center

4 Increased electrical charges in the brain during a seizure may disturb the cerebral thermoregulation center in the hypothalamus. Excessive muscular activity usually causes perspiration, leading to a drop in body temperature. One increased reading is not a conclusive sign of infection. Rapid fluid loss does not occur during a seizure; clients with preeclampsia have fluid retention.

Which drug may increase a client's body temperature when administered along with monoamine oxidase inhibitor? 1. Doxepin 2. Sertraline 3. Citalopram 4. Meperidine

4 Meperidine is a strong analgesic that may lead to an increased body temperature when used with monoamine oxidase inhibitors (MAOIs). Doxepin is a tricyclic antidepressant that may cause hypertension when taken with MAOIs. Sertraline and citalopram are serotonergic drugs that may increase the risk of serotonin syndrome when used with MAOIs.

While assessing a newborn, the nurse notes that the infant's skin is mottled. What should the nurse's primary intervention be? 1. Administer oxygen 2. Offer an oral feeding 3. Notify the practitioner 4. Warm the environment

4 Mottling results from hypothermia; the newborn should be wrapped, placed under a radiant warmer, or given to the mother for skin-to-skin contact. Mottling is a phenomenon that usually indicates a decreasing temperature; the newborn requires warming, not oxygenation or medical attention. Feeding will not increase the newborn's temperature.

Which is the first sign that would help the nurse in diagnosing malignant hyperthermia in a client? 1. Abnormal rapid heart rate 2. Abnormal rapid breathing 3. Increased body temperature 4. Increased expired carbon dioxide

4 The first sign of malignant hyperthermia [1] [2] is increased expired carbon dioxide, caused by an abnormal and continuous contraction of the skeletal muscles. Due to metabolic changes in the skeletal muscles, there may be abnormal rapid breathing (tachypnea) and abnormal rapid heart rate (tachycardia), but it is not considered the first sign of malignant hyperthermia. Increased body temperature is often late to appear during malignant hyperthermia.

A client with a head injury underwent a physical examination. The nurse observes that the client's temperature assessments do not correspond with the client's condition. An injury to which part of the brain may be the reason for this condition? 1. Pons 2. Medulla 3. Thalamus 4. Hypothalamus

4 The hypothalamus controls the body temperature. Damage to the hypothalamus may cause abnormalities in the body temperature values during a physical assessment. The pons is responsible for maintaining level of consciousness. The medulla controls heart rate and breathing. The thalamus performs motor and sensory functions.