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Which risk factor presents the greatest risk for injury in an older adult who is experiencing a dysfunction in temperature regulator function?
Delayed initiation of appropriate treatment
The provider is testing the client's ability to identify the specific location of skin touch in two different areas. This ability is communicated through which pathway?
Discriminative
Which intervention would be considered a nonpharmacologic method of pain control? Select all that apply.
Distraction by knitting Guided imagery Biofeedback
An older adult's blood cultures have come back positive, despite the fact that the client's oral temperature remains within normal range. Which phenomena underlies the alterations in fever response that occur in older adults?
Disturbance in the functioning of the thermoregulatory center
A client has a fever that was induced by damage to the hypothalamus due to intercranial bleeding. The nurse plans care for which type of fever?
Neurogenic
The nurse working in the delivery department knows that which factor is a primary risk for the newborn to develop hypothermia?
Newborns have a high ratio of surface area to body mass.
A client on an acute medicine unit with a diagnosis of small bowel obstruction is reporting intense, diffuse abdominal pain. Which physiologic phenomenon is most likely contributing to the client's pain?
Nociceptive afferents are conducting along the cranial and spinal nerve pathways of the ANS.
Which intervention is usually the first line of therapy when treating moderate pain in the older adult population?
Nonopioids such as acetaminophen
Nociceptors are sensory receptors that are activated by which type of stimuli?
Noxious stimuli
A client who has developed a fever is now reporting a headache. The nurse would recognize this manifestation as a result from the:
vasodilatation of cerebral vessels.
A client reports seeing flickering lights for about 10 minutes before developing nausea and a pounding right-sided headache. Which factors would correspond to a diagnosis of migraine headache? Select all that apply.
Family history of migraine Duration of 1-2 days Occurring with menstruation
Which assessment finding correlates to the prodromal stage of a fever?
Fatigue
How will the nurse explain to a client the changes in blood flow during exercise?
"Heat dilates blood vessels and increases local blood flow to skeletal muscles."
The nurse is working with a client who has been diagnosed with recurring migraine headaches. Which advice by the nurse is most appropriate?
"Many people find that maintaining regular eating and sleeping habits is beneficial."
A client who has been exercising says to the nurse, "My skin is so hot!" What is the nurse's best response?
"Your body is trying to lower your temperature."
Which temperature readings indicate to the nurse that the clients have fever? Select all that apply.
3-day-old with rectal reading of 38ºC (100.4ºF) 35-year-old with pulmonary artery reading of 37.9ºC (100.2ºF) 19-year-old with oral reading of 38.4ºC (101.1ºF)
A nurse is teaching a parent how to take an axillary temperature on the child. The nurse indicates that the glass thermometer should be held in the axillary fossa for which amount of time?
5 to 10 minutes
Which client(s) is showing manifestations of infection? Select all that apply.
75-year-old client with temperature 37.3°C (99.2°F), declining mental status, weakness and fatigue 25-year-old client with temperature 40°C (104°F), sweating, shivering, states generalized pain 2-month-old client with temperature 38.3°C (100.4°F), lethargy, poor feeding, and cyanosis
A nurse is working at the medical booth at a marathon on a hot summer day. Which individual is at greatest risk for hyperthermia?
83-year-old spectator with congestive heart failure
Infants are at greater risk of hypothermia than children because of which of the following?
A high ratio of surface area to body mass
An otherwise healthy client has been referred to a pain clinic because he is experiencing exquisite pain from the friction of his clothes on his torso. This client is likely to be diagnosed with which health problem?
Allodynia
A client has been diagnosed with a fever of unknown cause. The nurse recognizes this as:
A prolonged fever that does not have an identified source
A client diagnosed with moderate hypothermia would likely experience the instillation of warmed fluids into the gastrointestinal tract and extracorporeal blood warming. This type of rewarming is referred to as:
Active core
A nurse conducting a community education program on hypothermia includes which of the following as a risk factor?
Alcohol
Chronic pain is difficult to treat. Cancer, a common cause of chronic pain, has been especially addressed by the World Health Organization (WHO). What has WHO created to assist clinicians in choosing appropriate analgesics?
An analgesic ladder for pain control
A client reports general malaise and has a temperature is 103.8°F (39.9°C). What is the rationale for administering a prescribed aspirin, an antipyretic, to this client?
Antipyretics protect vulnerable organs, such as the brain, from extreme temperature elevation.
A diabetic client has developed diabetic neuropathy and is prescribed pharmacologic intervention. The medication most likely to be prescribed would be an:
Antiseizure
Which intervention is an appropriate action by a nurse to take in attempting to decrease a client's temperature through conduction?
Apply cooling blanket
A client who has cut a finger drops the knife in pain. Which component of this pain signal was transmitted by third-order neurons?
Between the thalamus and the cerebral cortex
Which factors influence pharmacologic choices for pain management in children? Select all that apply.
Body size requires dosage adjustment. Liver function is less efficient in an infant. One goal is to minimize side effects. Premature infants may have reduced renal function.
Nonshivering thermogenesis occurs in which of the following to help the newborn infant fight hypothermia?
Brown fat
What can the nurse assume about a child's behavior when faced with the need to repeat a painful procedure?
Children act to avoid pain based on their memory of past painful events.
A nurse is caring for several clients with a temperature elevation of 102°F (38.9°C). Which client would be the highest priority for the nurse?
Client with history of congestive heart failure
The nurse is assessing a client with an elevated temperature. Which additional assessment findings provide the most useful information for the nurse?
Client's heart rate is more rapid than anticipated.
A client taking the typical antipsychotic agent haloperidol experiences neuroleptic malignant syndrome. What nursing intervention is highest priority after stopping the medication?
Cooling blanket
An 80-year-old woman is undergoing total hip replacement surgery as treatment for severe osteoarthritis. During the procedure, the client's core temperature falls to 31.6°C (88.9°F), necessitating interventions to address her hypothermia. The surgical team recognizes that there are likely multiple causes of the client's hypothermia. Which factor would the team be most justified in ruling out as a contributor?
Decreased temperature adaptation due to her unconscious state
The term hypothermia occurring following submersion in cold water is associated with acute asphyxia. Children have been reported to survive after being submerged from 10 to 40 minutes. This situation is believed to be possible because of the rapid cooling process following a particular reflex. What is the name of that reflex?
Diving reflex
A client's body temperature has been documented as follows: 12 noon: 37°C (98.6°F); 6 pm: 37.5°C (99.5°F); 3 am: 36°C (96.8°F). Which action should the nurse take?
Document the temperature.
Which principles should underlie the pain control strategy in the care of a child with a diagnosis of cancer?
Dosing and timing should aim for a steady serum level of the prescribed drug.
The nurse is taking the history of a client scheduled for surgery with general anesthesia. What is the first response by the nurse to the client's statement that an uncle died after receiving general anesthesia?
Ensure the anesthesiologist is made aware of the information.
A nurse who is providing a staff development in-service determines that the participants understand the information when they state that which bodily function aids heat conservation by reducing surface area for heat loss?
Erection of pilomotor muscles
A hiker presents to the emergency department with reports of flu-like symptoms—thirst, nausea, and inability to urinate. Upon assessment, it is determined that the client has a rectal temperature of 102.2°F (39°C) and is tachycardic. These symptoms support a diagnosis of:
Heat exhaustion
An 8-year-old boy has fallen through the ice while skating on a frozen pond. By the time paramedics arrive, the boy has been removed from the water by his friends, but his core body temperature is 31.1°C (88.0°F). The responders would recognize that which physiologic process would have been active during the boy's accident?
Heat production through increased body metabolism
During an intense aerobic activity, how does the body regulate temperature during a well-trained athlete's workout?
Increasing heat loss by producing sweat
A febrile, 3-week-old infant is currently undergoing a diagnostic workup to determine the cause of the fever. Which statement conveys the rationale for this careful examination?
Infants are susceptible to serious infections, because of their decreased immune function.
A nurse is assessing a client for manifestations of chronic pain. Which finding is characteristic of chronic pain? Select all that apply.
Mental depression Loss of appetite Withdrawal from activities
There are two types of stimuli that affect the raising or lowering of body temperature. What are these stimuli?
Innocuous and noxious
A client has been diagnosed with osteomyelitis and admitted to the hospital. The client's fever persists throughout most of the day but returns to normal at least twice a day. Which pattern of fever is this client displaying?
Intermittent
A client's temperature readings are as follows: 99.6°F (37.5°C) at 4 pm; 102°F (38.9°C) at 8 pm; and 97.9°F (36.6°C) at 12 am. The nurse's hand-off should include which note?
Intermittent fever
A client reports a sudden intense headache. Which factor would indicate the presence of a possible subarachnoid hemorrhage?
Intractable pain
Children act to avoid pain based on their memory of past painful events.
Intractable pain
Which of the following types of pain is characterized by severe, brief, often repetitive pain?
Neuralgia
A client was skating on the lake when the ice broke and he was submerged for 15 minutes. When rescuers were able to retrieve him from the water, his core temperature was 31° C (87.8°F). Into which classification does this temperature fit?
Moderately hypothermic
Which statement explains how nonsteroidal anti-inflammatory drugs (NSAIDs) control pain?
NSAIDs block the enzyme that synthesizes prostaglandins.
A nurse is assessing an individual at an outdoor community health fair on a hot summer day and suspects heat exhaustion based on which symptoms? Select all that apply.
Nausea Oliguria
A client reports feeling a tingling sensation in the last two fingers of one hand after hitting the inner surface of the elbow on a desk. What is the cause of this symptom?
Paresthesia from temporary nerve compression
A nurse assesses a client with a cerebral infarct for sensation. Which result indicates that second-order neurons are intact?
Patellar reflex +2
Opioid receptors are highly concentrated in which region of the CNS and produce pain relief through the release of endogenous opioids?
Periaqueductal gray (PAG) region
Which client is exhibiting headache symptoms that indicate a need for further evaluation?
Pregnant mother with drowsiness and unrelenting headache
A client has a mild headache and fatigue. He also states he has some aches and pains. Which stage of fever does the nurse determine the client is experiencing?
Prodrome
A client in the intensive care unit has been having rapidly changing core body temperatures that requires close monitoring. The client is intubated and has a pulmonary artery catheter and a Foley catheter. The nurse should obtain and/or record the temperature from which of the following?
Pulmonary artery catheter
When assessing a newborn (7 days old), which finding indicates the infant may have a bacterial infection?
Rectal temperature of 100.4°F (38°C).
While a nurse is taking a client's history, the client states that he had a fever 2 days ago that went away for a day and then returned. The nurse documents this as being which type of fever?
Relapsing
The nurse is caring for a client with acute pain from broken humerus. Which direction will the nurse provide the client related to pain management?
Requesting pain medication before the pain is severe can reduce how much medication is needed.
A nurse is teaching a client with a history of migraines about methods to control attacks. Which instructions should the client implement when the migraine starts? Select all that apply.
Resting in a darkened quiet room Taking aspirin or an NSAID with caffeine Using intranasal medications if nauseated
A client who has been exercising for a few weeks begins to sweat as soon as he exercises. What will the nurse determine from this assessment?
The client is reacting normally.
A nurse is conducting a health promotion education program on heat cramps that cause painful muscle cramps. What is the likely cause of these cramps?
Salt depletion from heavy sweating
The nurse is studying sensory systems. She understands that signal transduction of an impulse to the thalamus for processing is accomplished by:
Second-order neurons
The nurse is conducting a community education course on hyperthermia and heatstroke. The nurse determines that the participants understand the information when they state that which bodily function increases core temperature?
Shivering
Full localization, discrimination of intensity, and interpretation of somatosensory stimuli requires processing by which region of the brain?
Somatosensory cortex
A client who is being treated for chronic low back pain is using a TENS unit for relief of pain. The nurse is aware that the use of this device is considered what type of pain relief?
Stimulus-induced analgesia
A client with pneumonia is admitted with these vital signs: temperature 99.7ºF (37.6°F), pulse 80 beats/min, respirations 18/minute, and BP 120/80 mm Hg. Which set of vital signs does the nurse anticipate when the client begins to shiver and requests another blanket several hours later?
T 100.9ºF (38.3°C), P 90/min, R 20/min, BP 126/80 mm Hg
Which client manifestation indicates signs of drug fever?
Temperature reaches 40°C (104°F) every afternoon, pulse 76 beats/minute, pruritis
A client who works in a high stress job presents with facial pain and severe headache. She reports that she sometimes feels the pain in her neck or ear and that it is particularly bad during very busy times at work. Which diagnosis is most likely associated with these symptoms?
Temporomandibular joint syndrome
The nurse learns that different types of headaches respond to different therapies. Which headache is most responsive to nonpharmacologic therapy?
Tension
A nurse caring for an older adult who has been diagnosed with a urinary tract infection checks the client's temperature on admission and finds that it is 96.6°F (35.9°C). Which statement describes how the nurse should interpret the finding?
The client may be exhibiting a blunted or absent febrile response.
A client who reports pain in the left ear and lower jaw is worried that the pain may indicate a heart attack. Which additional manifestations indicate that it is temporomandibular joint pain (TMJ)? Select all that apply.
The pain increases with jaw activity. There is an accompanying headache.
A student is feeling inside her backpack to find her mobile phone. There are a number of other items in the backpack. Which component of somatosensory conduction is most likely to provide the detailed sensory information that will help her distinguish her phone from other items?
The primary dorsal root ganglion neuron, dorsal column neuron, and the thalamic neuron
Children feel pain just as much as adults do. What is the major principle in pain management in the pediatric population?
Treat on individual basis and match analgesic agent with cause and level of pain.
A child age 33 days is presented to the emergency department of a hospital by her parents following a 2-day fever. Her temperature is 38°C (100.4°F) tympanically. Which diagnostic test is most clearly indicated?
Urine for culture and sensitivity
Which of the following is an accurate method of assessing pain in children ages 3 to 8 years?
Using a faces scale
A recovery room nurse monitoring a client for adverse effects of cold cardioplegia assesses for:
Ventricular dysrhythmia
A client is admitted to the acute care facility with severe pain in the abdomen related to inflammatory bowel disease. What type of pain will the nurse be administering medication to relieve?
Visceral pain
Which characteristic differentiates a migraine with aura from a migraine without aura?
Visual symptoms such as flickering lights precede the headache
Which client most likely faces the highest risk of neuroleptic malignant syndrome?
Young adult client who is taking antipsychotic medications for the treatment of schizophrenia
Stretch-sensitive receptors in the skin (Ruffini end organs, Pacinian corpuscles, and Merkel cells) help signal postural information and are processed through the:
dorsal column-medial lemniscus pathway.
A nurse is planning care for a client coming into the emergency department via ambulance on a hot summer day with the following symptoms: temperature of 105°F (40.5°C), absence of sweating, and loss of consciousness. The nurse presents this evidence to the health care provider as supporting which condition?
heatstroke
A nurse instructing unlicensed assistive personnel (UAP) on temperature regulation includes as part of the teaching that core body and skin temperatures are sensed by which part of the brain?
hypothalamus
The nurse is caring for a client who is experiencing dysregulation of body temperature. The nurse associates this dysfunction with which area(s) of the brain that are involved in sensing core body and skin temperatures? Select all that apply.
hypothalamus cerebral cortex thalamus
A client is said to be in the chill stage of the fever process when the nurse:
observes piloerection on the skin.
In the hospital setting, one of the best ways to lower the fever in a client with hyperthermia would be to facilitate conduction of heat from the body by:
placing the client on a cooling mattress that circulates a coolant solution through the mattress.
Which stimulus would be used to elicit the withdrawal reflex when testing response to nociceptive stimuli?
pressure from a sharp object
While sponging a client who has a high temperature, the nurse observes the client begins to shiver. At this point, the priority nursing intervention would be to:
stop sponging the client and retake a set of vital signs.
When lecturing about heart attacks (myocardial infarctions), the instructor will emphasize the client may present with: Select all that apply.
substernal chest pain. neck pain. pain that radiates to the left arm.
