Hesi Thermoregulation
What are the clinical manifestations of inhalation anthrax? Select all that apply.
Fever Correct 2 Fatigue Correct 4 Dry cough Correct 5 Sore throat
Which physiologic characteristics of newborns affect drug dosage considerations? Select all that apply.
A newborn's less regulated body temperature Correct 2 Immature liver and kidneys Correct 4 Lungs with weaker mucous barriers The body temperature of newborns is less regulated and dehydration occurs easily. This characteristic affects the drug dose consideration in newborns. Metabolism and excretion are impaired in pediatric clients due to an immature liver and kidneys. The lungs in pediatric clients have weak mucous barriers; this characteristic also affects the drug dosage considerations in newborns. A newborn's skin is thin and more permeable. The newborn has no acid in the stomach to kill the bacteria; therefore, drug absorption from the gastrointestinal tract is affected, thus impacting drug dosage considerations.
The nurse must continually assess a preterm infant's temperature and provide appropriate nursing care because, unlike the full-term infant, the preterm infant has what limitation?
Has a limited supply of brown fat available to provide heat Because neonates are unable to shiver, they use the breakdown of brown fat to supply body heat; the preterm infant has a limited supply of brown fat available for this purpose. An inability to use shivering to produce heat is not specific to preterm neonates; all newborns are unable to use shivering to supply body heat. The breakdown of glycogen into glucose does not supply body heat. Pituitary hormones do not regulate body heat.
A nurse plans to take the temperature of a 4-year-old child with a diagnosis of leukemia who has a fever. Which thermometers with the most accurate results can the nurse use safely for this child? Select all that apply.
Infrared, tympanic Chemical dot, axilla The infrared thermometer can be used on the tympanic membrane; it is safe to use for a child with leukemia. The chemical dot or liquid crystal skin contact thermometer is a flexible, one-use, disposable thermometer. It can be used to take oral or axillary temperatures and is safe for use in a child with leukemia. Rectal temperature taking is contraindicated in children with leukemia because it may result in trauma to the rectal mucosa. Also, the use of a rectal probe may be perceived as an intrusive procedure by a 4-year-old. Most digital thermometers can be used to take oral, axillary, or rectal temperatures. An oral temperature with an electronic thermometer is not safe or accurate for a 4-year-old; it is considered safe for a child who is at least 5 years old. The ear-based sensor thermometer is used in ambulatory settings; its reliability is a matter of some controversy.
A 7-year-old child who has sustained frostbite of the toes after skiing in below-freezing weather is brought to the emergency department. What is the nurse's initial intervention?
Rapidly rewarming the toes by placing the feet in warm water Rapid rewarming is accomplished by immersing the body part in well-agitated water at 100° F to 108° F (37.8° C to 42.2° C). Rapid rewarming minimizes tissue damage. The body part should be rewarmed as quickly as possible to minimize tissue damage. Prolonged exposure to the cold will worsen tissue damage.
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?
Removing excess clothing from the infant 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 primary healthcare provider prescribes the application of a warm soak to an intravenous (IV) site that has infiltrated. Which principle does the nurse determine is in operation when the application of local heat transfers temperature to the body?
Conduction is the conveyance of energy such as heat, cold, or sound by direct contact. Direct contact is not necessary to convey heat by radiation. Insulation refers to retention of heat, not its transfer. Convection is the transfer of heat by air circulation (e.g., by fans or open windows).
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?
Hypothalamus 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.
A client with a history of hypothyroidism reports giddiness, excessive thirst, and nausea. Which parameter assessed by the nurse confirms the diagnosis as heat stroke?
Increased heart rate Prolonged exposure to the sun or a high environmental temperature overwhelms the body's heat-loss mechanisms. These conditions cause heat stroke, which manifests as giddiness, excessive thirst, and nausea. An increased heart rate (HR) characterizes a heat stroke. A low blood pressure (BP), increased respiratory rate, and increased circulatory and tissue damage are not indicators of heat stroke.
A parent of a preterm infant asks a nurse in the neonatal intensive care unit why the baby is in a bed with a radiant warmer. The nurse explains that preterm infants are at increased risk for hypothermia because they
Lack the subcutaneous fat that usually provides insulation Much of a full-term infant's birth weight (almost a third) is gained during the last month of gestation, and most of this final spurt is related to an increase in subcutaneous fat, which serves as insulation; the preterm infant did not have enough time to grow in the uterus and therefore has little of this insulating layer. Preterm infants do not shiver or sweat. The preterm infant has a relatively larger surface area per body weight than does a term infant. Depressed antibody production is unrelated to maintenance of body temperature.
Which drug may increase a client's body temperature when administered along with monoamine oxidase inhibitor?
Meperidine 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.
A preterm neonate is receiving oxygen by way of an overhead hood. Which nursing interventions should the nurse implement to protect the infant under the oxygen hood?
Put a hat on the infant's head to prevent hypothermia Oxygen has a cooling effect, and the infant should be kept warm so metabolic activity and oxygen demands are not increased. Offering fluid every 15 minutes may produce fluid overload, which could in turn result in increased cardiac output; this is an undesirable outcome, especially for an infant with respiratory distress. Oxygen concentration is determined from blood gas levels and is changed accordingly. Removing the infant from the hood every 15 minutes will tire the infant and increase the need for oxygen.
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?
Body Temp 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.
A 6-year-old boy is sent to the school nurse on a snowy below-freezing day because he arrived without a coat, wearing shorts, a T-shirt, and sandals. What is the first nursing intervention?
Checking the child for frostbite The child must first be assessed for injuries caused by exposure and treated if necessary. A warm liquid may be offered after the child's physical status is assessed and it is determined that fluids may be ingested. Child Protective Services may be called after further assessment and the determination that neglect may be involved. Questions about the child's family dynamics may be asked after the status of the child is evaluated.
A nurse is reviewing the physical examination and laboratory tests of a client with malaria. Which important clinical indicators should the nurse watch for when reviewing data about this client? Select all that apply.
Correct 3 Hyperthermia Correct 4 Splenomegaly A high fever (hyperthermia) results from the disease process. Parasites invade the erythrocytes, subsequently dividing and causing the cell to burst. The spleen enlarges from the sloughing of red blood cells. Oliguria, not polyuria, occurs in malaria-induced kidney failure. Leukopenia does not occur. Erythrocytosis does not occur.
While assessing a neonate's temperature, the nurse observes a drop in the body temperature. What is the most appropriate reason for this temperature drop?
Decreased nonshivering thermogenesis Neonates are susceptible to heat loss or cold stress. Nonshivering thermogenesis is a natural mechanism of heat production that occurs to minimize heat loss in a neonate. This mechanism's failure may lead to a drop in body temperature. The basal metabolic rate (BMR) accounts for heat production; an increased BMR may raise the body temperature. Shivering is an involuntary movement that produces heat, which may not be seen in neonates. Voluntary movements cause increases in body temperature.
The nurse is caring for a client who recently returned from another country who exhibits signs and symptoms suspicious of severe acute respiratory syndrome (SARS). Which clinical manifestations support this diagnosis? Select all that apply.
Dry cough Correct 4 Shortness of breath Correct 5 Fever greater than 100.4° F (38° C) Between two and seven days after the onset of SARS, which is caused by a coronavirus, clients exhibit a dry cough. SARS is an acute viral respiratory infection that results in respiratory signs and symptoms, including difficulty breathing and shortness of breath. SARS, a viral infection, generally begins with a fever greater than 100.4° F (38° C), headache, and muscle weakness. Although clients may exhibit sinus tachycardia, chest pains are not a typical symptom associated with SARS. The cough associated with SARS is nonproductive, and hemoptysis does not occur.
Which is a characteristic of the glands that secrete a thick substance in response to emotional stimulation and become odoriferous because of bacterial action?
Grow in conjunction with axillary hair follicles The apocrine sweat glands secrete a thick substance in response to emotional stimulation and become odoriferous because of bacterial action. These glands grow in conjunction with hair follicles around the axillae. The apocrine glands are inactive during childhood and reach their secretory potential at the time of puberty. The apocrine glands are situated around the umbilicus. They have limited distribution and are found only around the axillae, areolae, external auditory canal, and anal and genital regions. Eccrine sweat glands, not the apocrine glands, have wide distribution throughout the body.
An older adult with chills arrived to hospital. The nurse assesses the client's vital signs and determined the client has a fever. What would be the client's rectal temperature?
In older adults the normal temperature range is 36° to 36.8°C orally and 36.6° to 37.2°C rectally. In febrile conditions, the rectal temperature would be more than 37.5°C. A rectal temperature of 38.5°C would indicate a fever.
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?
Irregularity in the cerebral thermal center 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.
The primary healthcare provider instructs the nurse to apply an emollient to an infant. During assessment, the nurse finds that the neonate is a preterm infant and has a body weight of 900 g. Which is the appropriate nursing intervention in this situation?
Monitor for coagulase-negative staphylococcus infection. Emollients can cause coagulase-negative staphylococcus infection in a preterm infant who weighs 900 g or less. Intravenous fluids do not increase the effectiveness of the emollients, so there is no need to administer intravenous fluids before applying the emollient. Emollients effectively reduce dry, flaking, and fissured areas on the infant's skin. Emollients are not contraindicated in preterm infants, so there is no need to hold application or recheck with the primary healthcare provider.
An older adult is brought to the emergency department after being found in the street without a coat during a snowstorm. What actions should the nurse implement? Select all that apply.
Obtain a rectal temperature. Correct 3 Assess the fingers for areas of frostbite. Correct 4 Determine client's level of consciousness. Correct 5 Ask for client identification A rectal temperature provides the most accurate temperature. Older adults have less subcutaneous fat and inefficient temperature-regulating mechanisms, which makes them vulnerable to extremes in environmental temperature. The extremities are more distal sites of circulation and are at increased risk for frostbite. Hypothermia decreases cerebral perfusion, which will result in confusion and a decreased level of consciousness. Getting client identification will help in learning more about the client's previous health history and aid in contacting family members. Massage is contraindicated because it may injure tissues that have sustained frostbite.
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.
Oral temperature of 98.2° F (36.8° C) Correct 2 Apical pulse of 88 beats per minute and regular Correct 4 Blood pressure of 116/78 mm Hg while in a sitting position 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%.
A nurse is caring for a mother and neonate. What is the priority nursing action to prevent heat loss in the neonate immediately after birth?
Putting the naked newborn on the mother's skin and covering the infant with a blanket Skin-to-skin contact between mother and infant is most effective in maintaining the infant's body temperature; heat is transferred by way of conduction. A radiant warmer is effective if the mother or newborn is unable to engage in immediate skin-to-skin contact. Dressing the newborn in a shirt and gown immediately is not effective; also, a blanket and radiant warmer are necessary if skin-to-skin contact with the mother is not possible. Bathing the infant should be delayed until the newborn's body temperature has been stabilized.
After surgery, a client's fever does not respond to antipyretics. The primary healthcare provider prescribes that the client be placed on a hypothermia blanket. What response to hypothermia therapy must the nurse prevent?
Shivering should be prevented; peripheral vasoconstriction increases the temperature, the circulatory rate, and oxygen consumption. Vomiting is not a response to hypothermia therapy. Dehydration is not a response to hypothermia therapy; presence of a fever can cause dehydration if oral or parenteral fluid intake is inadequate to maintain fluid balance. Hypotension is not a response to hypothermia therapy; hypotension can occur with dehydration if oral or parenteral fluid intake is inadequate to maintain fluid balance.
The nurse cares for a client who develops pyrexia 3 days after surgery. Which signs and symptoms commonly associated with pyrexia should the nurse should monitor the client for? Select all that apply.
Tachypnea Correct 4 Increased pulse rate Fever causes an increase in the body's metabolism, which results in an increase in oxygen consumption, causing tachypnea. Fever causes an increase in the body's metabolism, which results in an increase in oxygen consumption; this need for oxygen is met by an increased heart rate, which is reflected in an increased pulse rate. Although the respiratory rate may increase slightly, fever will not cause dyspnea. Chest pain is not related to the fever unless its cause is respiratory in nature. An increase in blood pressure does not necessarily accompany a fever.
A client was admitted to a surgical unit in an unconscious state due to head trauma. Which site would be most appropriate to obtain the client's temperature?
The axilla would be the most appropriate site to obtain a temperature measurement in a client who is unconscious due to head trauma. The oral route is not accessible when the client is unconscious. Because the client is in a surgical unit, his or her head may be covered. Therefore, obtaining a temperature measurement through the temporal artery or tympanic membrane may not be possible.
A registered nurse instructed the nursing assistive personnel (NAP) to measure the temperature of a client who reports chills and coldness. The nurse believes that the reading is inaccurate. What observations may have led to this conclusion? Select all that apply.
The client has a habit of breathing through his or her mouth. The client ingested juice 30 minutes before his or her temperature was taken
Which condition should be reported immediately to the primary healthcare provider?
The client with cervical biopsy should immediately report to the primary healthcare provider if experiencing a body temperature of 102° F with vaginal discharge. This is because fever and vaginal discharge that develops 48 hours after cervical biopsy may be the signs of infection related to the procedure. The client should take pain relievers for pelvic pain after colposcopy. Light vaginal bleeding for 1 to 2 days following hysterosalpingogram is common. If the amount of bleeding increases or extends beyond 2 days, the healthcare provider should be notified. Light rectal bleeding for a few days is common after prostate biopsy.
After surgery for insertion of a coronary artery bypass graft (CABG), a client develops a temperature of 102° F (38.9° C). Which priority concern related to elevated temperatures does a nurse consider when notifying the healthcare provider about the client's temperature?
A fever increases the cardiac output. Temperatures of 102° F (38.9° C) or greater lead to an increased metabolism and cardiac workload. Although diaphoresis is related to an elevated temperature, it is not the reason for notifying the healthcare provider. An elevated temperature is not an early sign of cerebral edema. Open heart surgery is not associated with cerebral edema. Fever is unrelated to hemorrhage; in hemorrhage with shock, the temperature decreases.
Which parts of the body assessed by the nurse would confirm a diagnosis of frostbite? Select all that apply.
Areas particularly susceptible to frostbite are the fingers, toes, and earlobes. These parts of the body should be assessed to determine frostbite. The axilla is generally used to assess the body temperature; this site is used to diagnose a fever. The forehead and upper thorax are assessed to detect diaphoresis.
Arrange the sequence of events occurring during a fever secondary to pyrogens in chronological order.
A true fever results from an alteration in the hypothalamic set point. Pyrogens act as antigens that trigger the immune system response. The hypothalamus reacts by raising the set point, thereby increasing the body temperature. Once the pyrogens are removed, the third phase of a febrile episode occurs. Heat loss responses are initiated when the hypothalamus set point drops.
While assessing a client with schizophrenia who is receiving chlorpromazine, the nurse finds lead pipe rigidity, sudden high fever, and sweating. Which drugs would be prescribed by the healthcare provider? Select all that apply.
dantrolene, bromocriptine Lead pipe rigidity, sudden high fevers, and sweating are symptoms of neuroleptic malignant syndrome; this condition is an adverse effect of chlorpromazine. Drugs used to treat this syndrome are dantrolene and bromocriptine. Loxapine, thiothixene, and haloperidol are the first-generation antipsychotics that should not be prescribed because these may lead to severe complications.
