Chapter 10

A nurse assessing an older adult for signs and symptoms of infection in the absence of a fever should assess for which of the following? Select all that apply.

Change in fuctional capacity Fatigue Decreased mental status

In which of the following patients with a transecting spinal cord injury should the nurse anticipate an impaired ability for temperature regulation?

inujury at T2

A patient is experiencing anorexia, myalgia, arthralgia, headache, and fatigue. The nurse should assess for which of the following?

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 working at the medical booth at a marathon on a hot summer day. Which of the following individuals are at greatest risk for hyperthermia?

83-year-old spectator with congestive heart failure

A patient has a mild headache and fatigue. He also states he has some aches and pains. Which of the following stages of fever does the nurse determine the patient is experiencing?

A 75-year-old, temperature 37.3°C (99.2°F), declining mental status, weakness and fatigue A 25-year-old, temperature 40°C (104°F), sweating, shivering, states generalized pain A 2-month-old, temperature 38.3°C (100.4°F), lethargy, poor feeding, and cyanosis

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 patient experiencing an increased temperature reports weakness and fatigue. Which of the following accurately accounts for these symptoms?

Epinephrine and norepinephrine shift the body metabolism to heat production rather than energy generation.

What is the most common cause of drug fever?

Hypersensitivity reaction to medication

A surgical patient is at greatest risk for hypothermia during a surgical procedure related to which of the following?

Impaired thermoregulatory mechanisms brought on by anesthesia

The nurse is assessing a patient with an elevated temperature. Which of the following additional assessment findings provides the most useful information for the nurse?

Patient's heart rate is more rapid than anticipated

Place the four successive stages of fever in correct order.

Prodromal Chill Flush Defervescence

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

A client with pneumonia is admitted with these vital signs: temperature 99.7ºF, pulse 80 beats/min, respirations 18/minute, and BP 120/80 mmHg. 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, P 90/min, R 20/min, BP 126/80 mmHg

Which symptom indicates the next stage of a fever after a prodrome

a chill

A nurse is planning care for a patient coming into the emergency department via ambulance on a hot summer day with the following symptoms: temperature of 105°F, absence of sweating, and loss of consciousness. The nurse anticipates that the patient has which of the following conditions?

heat stroke

Which of the following can the nurse tell a patient about antipyretic drugs during fever?

antipyretics help to protect the body

Which of the following is an appropriate action by a nurse to take in attempting to decrease a patient's temperature through conduction?

apply cooling blanket

Infants are at greater risk of hypothermia than children because of which of the following?

high ratio of surface are to body mass

Nonshivering thermogenesis occurs in which of the following to help the newborn infant fight hypothermia?

brown fat

The loss of heat from the body through the circulation of air currents is known as which of the following?

convection

Which assessment finding correlates to the prodromal stage of a fever?

fatigue

Most febrile illnesses are due to common infections and are relatively easy to diagnose. In certain instances, however, it is difficult to establish the cause of a fever. In these instances, the elevation in temperature is referred to as a fever of unknown origin (FUO). What is a common cause of FUO?

malignancies

A patient has a fever that was induced by damage to the hypothalamus due to intercranial bleeding. The nurse plans care for the patient with which of the following types of fever?

neurogenic

A two-day postoperative patient's temperature was 98.5°F at 3:00 pm. At 6:00 pm, the unlicensed assistant notifies the nurse that the patient's temperature is 102.0°F. Which of the following actions should the nurse take?

notify physician

A patient has a mild headache and fatigue. He also states he has some aches and pains. Which of the following stages of fever does the nurse determine the patient is experiencing?

prodrome

An elderly client is dressed only in a hospital gown requests a warm blanket for "a draft in her room." Which mechanisms of heat loss is most likely the primary cause of her request?

radiation and convection

The nurse needs to assess a 1-year-old child for fever. Which approach will produce the most accurate reading?

rectal

Antipyretic drugs, such as aspirin, ibuprofen, and acetaminophen, are often used to alleviate the discomforts of fever and protect vulnerable organs, such as the brain, from extreme elevations in body temperature. The use of aspirin is limited in children, however, because it can sometimes cause which of the following diseases?

reye syndrom

The nurse is conducting a community education course on hyperthermia and heat stroke. The nurse determines that the participants understand the information when they state that which of the following increases core temperature?

shivering

A client presents with a temperature of 38.8°C (101.8°F), a racing heart, fatigue, and an upset stomach after working outside in a hot day. Which assessment findings suggest fever rather than hyperthermia as a cause of the elevation in the man's temperature? Select all that apply.

shivering, pallor

A recovery room nurse monitoring a patient for adverse effects of cold cardiplegia assesses for which of the following?

ventricular dysrhythmias