Pearson Thermoregulation
The nurse is planning care for a patient who has a fever and dry mucous membranes. Which intervention should the nurse include in the plan of care? A. Administering lip balm for lubrication B. Keeping the air conditioner on in the room C. Inserting an indwelling urinary catheter D. Changing the bed linens frequently
Answer: A If the lips and oral cavity are cracked, they are a portal of entry into the body for infection. Therefore, the nurse would provide the patient lip balm to lubricate the lips. Turning on the air conditioner will cool off the environment. Changing the bed linens frequently eliminates dampness from sweating. Insertion of a urinary catheter monitors output, which can help monitor for renal failure.
The nurse admits a client diagnosed with moderate hypothermia. Which finding should the nurse expect to observe during the physical assessment? A. Absence of shivering B. Tachycardia C. Tachypnea D. Flushing
Answer: A Rationale: Flushing, tachypnea, and tachycardia are indicative of hyperthermia. Absence of shivering occurs when a client has reached at least moderate hypothermia.
Which action should be performed to treat a child with a fever? (Select all that apply.) A. Checking temperature every 2 hours with a thermometer B. Monitoring response to antipyretic medication C. Sponging with rubbing alcohol D. Keeping fully dressed E. Providing alternating doses of ibuprofen and acetaminophen
Answer: A, B Rationale: When treating a child with a fever, the child's response to antipyretic medication should be monitored and temperature should be checked every 2 hours. The child should be wearing a light layer of clothing. Alcohol should not be used to sponge the child. Alternating doses of ibuprofen and acetaminophen should not be provided.
The nurse is planning care for a client who has hyperthermia, dehydration, nausea and vomiting. Which intervention should the nurse include to restore fluid volume? (Select all that apply.) A. Providing antiemetics B. Administering fluids C. Changing damp clothes D. Providing warm blankets E. Padding the side rails
Answer: A, B, C Rationale: The goal for the client with a fluid volume deficit is to restore fluid volume. This should be done with oral and prescribed intravenous (IV) fluids. The nurse would provide antiemetics to stop nausea and vomiting to prevent further fluid losses. Damp clothing and linens trap in moisture, making fluid losses worse. The nurse would pad the side rails for febrile seizures, not fluid volume deficit. Warm blankets would make the person warmer.
The nurse is caring for a newly admitted client with a body temperature of 39.4°C (103°F). Which is an independent action that the nurse may perform to help reduce the fever? (Select all that apply.) A. Removing unnecessary clothing B. Turning on the circulating fan in the client's room C. Providing the client with cold water to drink D. Applying a cool cloth to the back of the neck E. Administering an average dose of acetaminophen
Answer: A, B, C, D Rationale: Independent nursing interventions for the client with a fever include removing unnecessary clothing, applying a cool cloth to the back of the neck, providing cold oral fluids, and turning on the circulating fan in the client's room. A healthcare provider's order is needed before administering medications to the client.
The nurse is visiting an older adult client who lives at home alone. Which assessment should the nurse make to determine the risk of hypothermia? (Select all that apply.) A. Medications used B. Financial concerns C. Diet D. Blood glucose E. Physical activity
Answer: A, B, C, E Rationale: Diet, physical activity, medications, and financial stress can all increase the risk of hypothermia in older adults. Blood glucose level at one point in time will not indicate future risk of hypothermia.
The nurse is planning care for a client with a temperature of 41.0°C (105.8°F). Which priority intervention should the nurse include? (Select all that apply.) A. Changing the linens frequently B. Padding the side rails C. Providing immunizations D. Administering acetaminophen E. Giving the client a cool bath
Answer: A, B, D Rationale: An elevated temperature coinciding with a serious infection can precipitate febrile seizures. Therefore, the nurse should pad the side rails for safety. The nurse should administer antipyretics such as acetaminophen to provide comfort and reduce body temperature. As the client sweats, the linens will become damp. Therefore, the nurse should change the linens frequently. Cool baths may increase shivering and discomfort; therefore, a tepid bath should be given. It is not recommended that clients receive immunizations during a serious respiratory infection.
The nurse is performing an admission assessment on an adult client with hypothermia. Which data should the nurse anticipate collecting during the health history portion of the nursing assessment? (Select all that apply.) A. History of financial difficulties B. History of exposure to environmental elements C. Blood pressure D. Drug or alcohol use E. Delayed capillary refill
Answer: A, B, D Rationale: During the health history portion of the nursing assessment, the nurse will assess the client's history of exposure to environmental elements and any financial difficulties that may prevent the client from adequately heating his home. The nurse would also anticipate a drug and alcohol history, which can place the client at a greater risk for hypothermia. The client's blood pressure and capillary refill are assessed during the physical exam portion of the nursing assessment.
Which problem should be considered when planning care for a client with hyperthermia? (Select all that apply.) A. Fluid balance B. Temperature regulation C. Pain control D. Skin integrity E. Oral mucous membrane status
Answer: A, B, D, E Rationale: Problem categories to include in the plan of care for a client with hyperthermia include fluid balance, skin integrity, temperature regulation, and oral mucous membrane status. Pain control is not necessarily a problem when planning care for a client with hyperthermia.
A client with a fever reports feeling hot and miserable. Which action should the nurse perform to help this client achieve comfort? (Select all that apply.) A. Turning on the circulating fan in the room B. Administering antipyretics as prescribed C. Removing unnecessary clothing D. Changing damp bed linens E. Measuring temperature every 2 hours
Answer: A, C, D Rationale: Actions to promote comfort in the client with a fever include changing damp bed linens to keep the client's skin dry, removing unnecessary clothing to reduce the feeling of heat, and turning on the circulating fan in the room to help dissipate the heat coming from the client's skin. Measuring temperature every 2 hours and administering antipyretics would be actions to reduce the client's body temperature.
The nurse is caring for an older adult patient who has a fever and is on bedrest. Which is the priority nursing intervention for this patient? A. Administering an antipyretic according to the prn order B. Performing a full skin assessment C. Monitoring the patient's temperature every 30 minutes D. Applying ice packs to the patient's groin
Answer: B A bedbound patient is at high risk for impaired skin integrity or pressure ulcers. The nurse's first priority is to assess the skin to look for signs of infection that could be causing the fever. Administering antipyretics or ice packs can help reduce the fever, but the nurse should first assess the patient. Frequent monitoring of the patient's temperature is also important, but it is not the first step.
An older adult patient tells the nurse that they are always cold. The nurse understands that which physiological change is the cause of this patient's discomfort? A. An increase in subcutaneous fat B. Less efficient thermoregulation C. Presence of brown adipose tissue and fat D. A high-fat, high-protein diet
Answer: B Older adults can be at risk for hypothermia because of less efficient thermoregulation. This causes older adults to be sensitive to extremes in environmental temperatures. Eating a high-fat, high-protein diet does not increase the risk for hypothermia. There is a decrease, not an increase, in the amount of subcutaneous fat in older adults. Newborns, not the older adults, have brown adipose tissue.
An adult presents with severe heatstroke and hyperthermia. Which collaborative intervention should the nurse expect to implement to prevent renal failure in this patient? A. Assessing body temperature hourly B. Administering intravenous fluids C. Inserting an indwelling catheter D. Monitoring BUN and creatinine
Answer: B The best way to prevent renal failure in a patient with heatstroke and hyperthermia is to provide intravenous fluids. The kidneys need a certain amount of fluid in the blood to filter. The nurse could insert an indwelling catheter, but this will not prevent renal failure. It will provide an accurate measurement of urinary output. Monitoring the BUN and creatinine does not prevent renal failure. It monitors renal function. The nurse would assess the body temperature every 1 to 2 hours to determine effectiveness of antipyretics or antibiotics. This does not prevent renal failure.
A woman who is 26 weeks' gestation presents with a temperature of 93.9°F (34.4°C) and severe shivering. Which nursing intervention is the priority? A. Support respiratory and cardiac function. B. Apply warming pads and begin fetal monitoring. C. Rapidly rewarm the affected areas in circulating warm water. D. Place a hat on the patient's head.
Answer: B Treatment of hypothermia for pregnant women follows the same guidelines as for adults. However, obstetric consultation and fetal monitoring should be added.
Parents of a 7-year-old child present to the healthcare provider's office and report that the child has been febrile for 3 days. Which action reported by the parents indicates a need for education? A. Providing popsicles and sports drinks B. Giving aspirin to alleviate fevers C. Applying ice packs to the axilla and groin D. Changing linens and clothing frequently
Answer: B Rationale: Aspirin should not be given to children with fevers due to the risk of Reye syndrome. This action requires intervention by the nurse for further teaching. Providing popsicles and sports drinks corrects fluid losses. Changing the linens and clothing frequently can eliminate extra moisture from sweating. Applying ice packs to the axilla and groin can help lower body temperature.
The nurse is caring for a client who has a wound infection and fever. Which collaborative intervention would best alleviate the fever? A. Encouraging IV and PO fluids B. Administering antibiotics C. Padding the side rails of the bed D. Using cooling blankets
Answer: B Rationale: The best way to alleviate the fevers related to a wound infection is to administer prescribed antibiotics. Use of cooling blankets will promote comfort, not alleviate fevers. IV and PO fluids prevent dehydration. Padding the side rails prevents injury from febrile seizures.
A client presents with hypothermia and frostbite of the toes with necrosis. Which clinical therapy should the nurse anticipate in response to the client's presentation? A. Protect blisters from tearing. B. Prepare for amputation as necessary. C. Rub areas of frostbite. D. Place areas of frostbite in a basin of standing warm water.
Answer: B Rationale: The nurse should prepare the client for amputation as necessary. The nurse should not rub or massage areas of frostbite, which can cause further vascular and tissue damage. The nurse should debride any blisters and place areas of frostbite in circulating warm water, not standing warm water.
Parents of a child with a fever call the clinic nurse to ask about administering an antipyretic. Which instruction is most important for the nurse to provide? A. "Provide extra fluids by giving popsicles, sports drinks, and flavored gelatin." B. "Antipyretics are dosed by weight, so read the label for the appropriate dose." C. "Wake the child up at night to administer an antipyretic around the clock." D. "Bring the child in to see the healthcare provider if there is no improvement in 24 hours."
Answer: B Rationale: The parents are asking about dosing an antipyretic for their child. Therefore, the nurse would instruct on administering the appropriate dose. It is important for the nurse to instruct about different ways to administer fluids, but this is unrelated to medication dosing. The nurse would not instruct the parents to wake the child to administer antipyretics. The nurse would instruct the parents to see the healthcare provider if there is no improvement in 4 days, not 24 hours.
An older adult has been admitted with hypothermia after being found unresponsive at home. Which intervention should the nurse expect to implement? (Select all that apply.) A. Administer IV solutions at room temperature. B. Gradually rewarm the client using a heating blanket. C. Make a referral to social services. D. Utilize a continuous core temperature-monitoring device. E. Rub the client's hands and feet vigorously.
Answer: B, C, D Rationale: A referral to social services is appropriate to identify ways to reduce the risk of future incidences of hypothermia. The client should be gradually rewarmed with a heating blanket. It is appropriate to use a continuous core temperature-monitoring device. Manual stimulation should be reduced. Warm IV solutions should be administered. Room temperature is not warm enough for administering IV solutions.
Which characteristic of a toxic appearance should a nurse expect to observe in a child with a fever? (Select all that apply.) A. Irritability B. Blue-tinged lips C. Lethargy D. Capillary refill of 6 seconds E. Respiratory rate of 8 breaths per minute
Answer: B, C, D, E Rationale: Characteristics of a toxic appearance in children include lethargy, poor perfusion, hypoventilation, and cyanosis. Lethargy, blue-tinged lips, capillary refill of 6 seconds, and a respiratory rate of 8 breaths per minute are characteristics consistent with a toxic appearance in a child. Irritability is not a characteristic of a toxic appearance in a child.
From an assessment of vital signs, the nurse learns that a client has a body temperature of 35.7°C (96.2°F). Which action should the nurse take? (Select all that apply.) A. Administer a tepid sponge bath. B. Cover with a warmed blanket. C. Provide oral hygiene. D. Cover the head with a cap. E. Provide warm oral fluids.
Answer: B, D, E Rationale: Nursing actions for a client with hypothermia include providing warm oral fluids, covering the head with a cap, and covering the client with a warmed blanket. Oral hygiene and a tepid sponge bath are interventions appropriate for a client experiencing hyperthermia.
The nurse caring for a client with hypothermia understands the compensatory mechanisms that are activated during this condition to decrease oxygen demands on the body. Which clinical manifestation should the nurse expect upon assessment for this client? (Select all that apply.) A. Increased GI motility B. Decreased heart rate C. Increased respiratory rate D. Increased heart rate E. Decreased respiratory rate
Answer: B, E Rationale: A decrease in the metabolic rate decreases oxygen demands on the body during hypothermia. This compensatory mechanism causes a decrease in both the respiratory rate and the heart rate. GI motility is not increased in hypothermia.
The nurse is caring for a 17-year-old patient with hypothermia and frostbite who spent the night outside in the elements after passing out from binge drinking. The nurse should recognize that which process increased the risk of hypothermia for this patient? A. Alcohol increases the viscosity of the blood, increasing the risk of ice crystals. B. Alcohol increases the intracellular sodium content, lowering the freezing point of the tissues. C. Alcohol causes peripheral vasodilation, causing a faster drop in body temperature. D. Alcohol causes peripheral vasoconstriction, causing decreased blood flow to the extremities.
Answer: C Alcohol causes peripheral vasodilation, causing a faster drop in body temperature. Alcohol does not increase blood viscosity or intracellular sodium levels.
The nurse determines that a patient with an elevated body temperature is in the plateau phase of the fever. Which assessment finding led the nurse to this conclusion? A. The patient is asking for another blanket. B. The patient is sweating. C. The patient feels neither hot nor cold. D. The patient is shivering.
Answer: C During the plateau phase of a fever, a new temperature has been met in the body, and the individual feels neither hot nor cold. During the flush phase, the cause of the fever is removed or treated, and the hypothalamic thermostat is suddenly reduced to a lower level. The body responds by excessive sweating. During the chill phase, the body performs actions to raise the temperature, including shivering and feeling cold.
The nurse is assessing a patient who has a core body temperature of 35°C (95°F) after being found outside in the cold. How should the nurse document this finding? A. Normothermia B. Severe hypothermia C. Mild hypothermia D. Hyperthermia
Answer: C Mild hypothermia ranges from 32° to 35°C (89.6° to 95°F). Normal body temperature ranges between 36°C (96.8°F) and 38.5°C (101.3°F), while hyperthermia is above 41.2°C (106.1°F). More severe hypothermia is diagnosed when body temperature drops below 28°C (82.4°F).
A 7-year-old child presents with decreased pulse and respirations, severe shivering, and chills. The child's parent states the child has been playing outside in the snow without a coat. Which intervention should the nurse implement first? A. Remove clothing and assess for frostbite. B. Immediately administer anti-inflammatories. C. Provide dry clothing and warm blankets. D. Administer warm whirlpool therapy.
Answer: C Rewarming the child is the first priority. Removing the clothing would not warm the patient. Anti-inflammatories and whirlpool therapy would be administered for severe hypothermia. Other interventions for moderate hypothermia include keeping limbs close to the body, using a hat or cap to cover the top of the patient's head, supplying warm oral or IV fluids, and applying warming pads.
The nurse is working at a summer camp when the heat index is predicted to be over 100°F (37.8°C). Which child should remain indoors? A. A child with seasonal allergies B. A child with cerebral palsy C. A child with asthma D. A child with a fractured arm
Answer: C The child with asthma should not be allowed outside during extremely hot temperatures, because this can exacerbate the condition. It may be contraindicated for the child with cerebral palsy and the child with a fractured arm to play contact sports. Seasonal allergies would not be affected by hot temperatures.
Which client is at the greatest risk for hypothermia? A. A pregnant woman in her first trimester B. A 3-hour-old infant swaddled in a blanket, wearing a hat, and being held by the mother C. An 89-year-old client on a fixed income during cold winter months D. A worker who repairs industrial freezers
Answer: C Rationale: Older adult clients are at risk for hypothermia if they try to save money by decreasing or turning off their heat during cold months. During pregnancy, core body temperature increases during the first trimester. Newborns are at risk for hypothermia, but swaddling and covering their heads with hats will help prevent it. The worker may be at risk for hypothermia but is likely to be wearing protective gear.
The nurse provided teaching to a first-time new mother about preventing hypothermia in her baby. Which client statement indicates that the teaching is effective? (Select all that apply.) A. "My baby is at risk for hypothermia because she has a thick layer of subcutaneous fat." B. "Oral thermometers are an effective method to take my baby's temperature." C. "I can use a pacifier thermometer to take my baby's temperature." D. "My baby should wear a hat to avoid heat loss." E. "My baby will shiver if she is cold."
Answer: C, D Rationale: Wearing a hat is an effective method of minimizing heat loss. A pacifier thermometer may be used at home to monitor an infant's temperature. Shivering in newborns is a late sign of hypothermia, as other physiological mechanisms are activated first to increase heat production. Oral thermometers should not be used in infants because they can break if bitten. Infants have very thin layers of subcutaneous fat, which place them at risk for hypothermia.
The nurse is assessing clients at a community health fair for risk of hypothermia. Which question by the nurse is appropriate? (Select all that apply.) A. "Does your newborn regularly get exposure to natural sunlight?" B. "Do you see your doctor at least twice a year for routine checkups?" C. "Do your children have coats, hats, and gloves to wear at the bus stop?" D. "How often do you drink alcohol?" E. "How do you budget for increased heating bills in the winter?"
Answer: C, D, E Rationale: Alcohol causes peripheral vasodilation, which increases the risk of hypothermia. Financial stress can impact a client's ability to heat the home during winter. During winter, children need layered clothing to protect from heat loss. Exposing a newborn to natural sunlight will not decrease the risk of hypothermia. One annual checkup is recommended.
The nurse is caring for a client diagnosed with frostbite. The nurse understands that which process occurs when tissue freezes? (Select all that apply.) A. Thinning of the blood occurs. B. Intracellular potassium increases. C. Vascular permeability occurs. D. Tissues and cells become edematous. E. Ice crystals form.
Answer: C, D, E Rationale: As human tissue freezes, ice crystals form, increasing intracellular sodium (not potassium). Vascular permeability occurs, along with an increased viscosity of blood. This leads to cellular and tissue edema.
The nurse is teaching a class about the clinical manifestations of hypothermia. Which information should the nurse include? (Select all that apply.) A. If frostbite is noted, the area should be rubbed vigorously. B. Clients diagnosed with hypothermia should be encouraged to ambulate. C. The clinical presentation of the client should determine the severity of hypothermia. D. A client diagnosed with hypothermia who is unresponsive and without a pulse should be declared dead. E. Clients diagnosed with hypothermia should undergo a complete body survey.
Answer: C, E Rationale: The severity of hypothermia is determined by the client's clinical presentation. All clients diagnosed with hypothermia should undergo a complete body survey. Clients with hypothermia, especially those with frostbite, should be on bedrest. A pulseless, unresponsive client with hypothermia should not be declared dead because hypothermia reduces oxygen demands. Areas with frostbite should not be rubbed or massaged.
The nurse is caring for a newborn that has a temperature of 96.9°F (36.05°C). How should the nurse help the newborn regulate its temperature? A. Undress the newborn and place them in a radiant warmer. B. Maintain a very warm thermal environment. C. Rapidly rewarm the child when necessary. D. Maintain a neutral thermal environment.
Answer: D When caring for a hypothermic newborn or infant, the nurse should maintain a neutral thermal environment (NTE) and warm the child slowly. The nurse should not undress the newborn and place them in a radiant warmer; rather, the nurse should swaddle the newborn and cover the scalp.
Which client is most at risk to develop hypothermia? A. A teenager who plays high school football B. A 4-year-old diagnosed with croup C. An older adult on a fixed income who lives with his son D. A 3-year-old who lives near a pond
Answer: D Rationale: A 3-year-old is at risk for falling into the pond and suffering from hypothermia. The child with croup and the teenager playing football are both at risk for hyperthermia. The older adult is on a fixed income, but he lives with his son, so his risk of hypothermia from inability to pay for heat is lowered.
The nurse is planning care for a client admitted with a diagnosis of moderate hypothermia. Which intervention is most appropriate to include in the plan of care? A. Perform diligent oral care. B. Minimize heat exposure. C. Closely monitor for dehydration. D. Handle the client gently to avoid cardiac stimulation.
Answer: D Rationale: Cardiac stimulation in a client with hypothermia can lead to cardiac arrest. Dehydration and minimizing heat exposure are appropriate interventions for a client with hyperthermia. Cracks in the oral mucosa are a concern with dehydration, which is a greater risk in hyperthermia.
The nurse is planning a presentation regarding hyperthermia prevention in the older adult. Which information is most important for the nurse to include? A. Avoiding hot tubs and saunas B. Increasing oral fluid intake C. Avoiding strenuous exercise D. Obtaining immunizations
Answer: D Rationale: The best way older adults can prevent hyperthermia is to prevent infection. This includes obtaining needed immunizations. Pregnant clients should avoid hot tubs and saunas. A person with cardiac disease should avoid strenuous exercise. Oral fluid intake should be increased in a client with hyperthermia to offset fluid losses from perspiration and fever.
The nurse is caring for a client diagnosed with hypothermia. Which observation indicates to the nurse that the treatment is effective? A. The client's core temperature is 33.7°C (92.6°F). B. The client begins shivering. C. The client is unable to generate her own heat. D. The client reports thermal comfort.
Answer: D Rationale: Thermal comfort indicates normal thermoregulation. Shivering, decreased core body temperature, and inability to generate heat are all indications that the client is still in hypothermia.
The nurse assesses a patient and finds a temperature of 38.3°C (101°F). The patient does not report feeling warm or cold. In which phase of the fever should the nurse suspect the patient to be in? A. Flush B. Resolution C. Plateau D. Chill
Answer: C In the plateau phase, the patient is febrile but does not report being hot or cold. The chill phase causes a person to feel chilled. People in the flush phase report being warm and flushed. There is no resolution phase.
A patient presents with superficial frostbite on the nose, ears, and hands. Which assessment finding should the nurse consider consistent with superficial frostbite? A. Stiffness of affected areas B. Presence of gangrene C. Yellow appearance of affected areas D. White appearance of affected areas
Answer: D Superficial frostbite causes a white, cyanotic, or reddened appearance of affected areas. A yellow appearance, stiffness, and presence of gangrene occur with deeper frostbite.
The nurse is assessing a client diagnosed with heat stroke. Which clinical manifestation should the nurse expect? A. Pale and clammy skin B. Pharyngitis C. Nausea and vomiting D. Absence of sweating
Answer: D Rationale: A symptom of heat stroke is warm facial flushing without sweating. Pharyngitis can accompany a fever in mononucleosis but not heat stroke. The person with heat exhaustion, not heat stroke, will report nausea, vomiting, and pale, clammy skin.
The nurse is assessing a patient who was found sleeping in a park in the snow. The nurse should ask the patient about which risk factor? A. Living situation B. Skin disorders C. Educational level D. Trauma
Answer: A Living situation and socioeconomic status are important considerations and risk factors for hypothermia. Both can cause a person to be living outside or on the streets with exposure to the cold. Skin disorders, trauma, and educational level are also important, but they are not the priority question for this patient.
The nurse caring for a client with fever should assess for which clinical manifestation? (Select all that apply.) A. Tachycardia B. Hypotension C. Tachypnea D. Fatigue E. Malaise
Answer: A, C, D, E Rationale: Clinical manifestations of a fever include fatigue, malaise, tachypnea, and tachycardia. Hypotension is not a clinical manifestation of a fever.
Which activity should the nurse instruct the pregnant client to avoid to prevent hyperthermia? (Select all that apply.) A. Hot outdoor summer temperatures B. Tepid baths C. Tanning beds D. Drinking too many fluids E. Saunas and hot tubs
Answer: A, C, E Rationale: Pregnant women should avoid any situations where the fetus is exposed to heat due to possible birth defects. Therefore, tanning beds, saunas, hot tubs, and hot summer temperatures should be avoided. Tepid baths are ideal, and pregnancy increases the client's fluid needs.
The nurse is assessing an older adult patient who was outside in 100°F (37.78°C) weather. Which finding indicates that the patient may be experiencing heatstroke? A. Pain B. Ruddy complexion C. Confusion D. Hypertension
Answer: C Signs of heatstroke include irritability, confusion, stupor, and coma. Pain is a sign of hypothermia. Hypotension, not hypertension, is a sign of a heat injury. Patients with hyperthermia have a pale, rather than ruddy, complexion.
A 4-month-old infant presents with a respiratory infection and a fever of 40.5°C (104.9°F). The nurse notices that the infant is sweating and breathing faster. Which finding is most important to note in the assessment? A. Difficulty nursing B. Lethargy C. Positive Babinski sign D. Nasal congestion
Answer: B A child with fever may present with a toxic appearance. This includes lethargy, cyanosis, poor perfusion, and hypoventilation or hyperventilation. Nasal congestion would be expected in a child with a respiratory virus. Difficulty nursing may be due to the nasal congestion, but can be corrected if the nasal congestion is resolved. A positive Babinski sign is expected in an infant.
An older adult was found unresponsive in the home. The heat was off and the environment was cold. The patient has cyanotic nail beds, a weak pulse, and slow capillary refill. Which finding should the nurse anticipate? A. Core body temperature 98.6°F (37°C) B. Core body temperature 101.8°F (38.8°C) C. Core body temperature 82.6°F (28.1°C) D. Core body temperature 106.2°F (41.2°C)
Answer: C The patient is in moderate hypothermia with a core body temperature of between 82.4°F and 89.6°F; 98.6°F is a normal core body temperature; 101.8°F indicates possible heat exhaustion; and 106.2°F indicates possible heatstroke.
The nurse provided discharge teaching to a patient with frostbite of their nose. Which patient response indicates the teaching was successful? A. "I will gently message my nose several times a day." B. "I will rub the skin of my nose with a washcloth daily." C. "I will not touch my nose until it is fully healed." D. "If blisters occur, I will keep them covered with a bandage."
Answer: C The patient needs to understand that touching their nose could cause further damage to the tissue. The patient should also understand that they should not rub or massage their nose because this will cause further tissue damage. Any blisters that appear should be debrided, not covered.
Which intervention may help prevent febrile seizures in toddlers attending daycare? (Select all that apply.) A. Providing areas of shade when playing outdoors B. Providing refrigerated fluids C. Increasing the amount of fresh fruit provided D. Reducing playtime outdoors during hot weather E. Reducing the length of scheduled nap times
Answer: A, B, D Rationale: Interventions to prevent the onset of a febrile seizure include providing refrigerated fluids, reducing play periods outdoors during hot weather, and protecting children playing outdoors with areas of shade. Reducing the length of nap time and increasing the amount of fresh fruit will not prevent the development of febrile seizures in toddlers.
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. Respiratory C. Musculoskeletal D. Neurologic E. Gastrointestinal
Answer: A, B, E 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 is caring for a patient diagnosed with hypothermia. Which assessment finding should the nurse expect? A. Cyanotic nail beds B. Flushed skin C. Capillary refill of 2 seconds or less D. Bounding pulse
Answer: A Cyanotic nail beds are a sign of hypothermia. Other signs of hypothermia include a weak pulse, slow capillary refill, and pallor.
An older adult patient presents with hypothermia. The nurse should consider which process as contributing to the risk for this patient? A. The normal aging process decreases pain tolerance. B. The normal aging process decreases metabolism. C. The normal aging process decreases the ability to shiver. D. The normal aging process decreases safety awareness.
Answer: B The older adult patient is at greater risk for developing hypothermia due to the normal aging process of decreased metabolism. Aging does not decrease pain tolerance or the body's ability to shiver. While many older adult patients have alterations of safety awareness, this is not necessarily a result of the normal aging process.
A 5-year-old is brought to the emergency department by their parents after experiencing a seizure. The mother asks, "Does this mean that my child has epilepsy?" Which response by the nurse is accurate? A. "No. High temperatures can cause seizures in young children." B. "Yes. Having any seizure means the child has a seizure disorder." C. "Yes. Most children who have a seizure from fever have epilepsy." D. "No, but your child will have seizures with a high fever."
Answer: A A fever can lead to the development of a febrile seizure or a generalized seizure that occurs in children as a result of a rapid temperature increase. This temperature increase is associated with an acute illness and is seen in children from age 6 months to 5 years. More than one-third of all children who have a febrile seizure will have another one; however, this does not diagnose the child with epilepsy. If the child is older when the first seizure occurs, the likelihood that another seizure will occur is less. Having a febrile seizure does not mean that the individual has epilepsy.
A patient phones the clinic and states, "I've been sweating and have a temperature of 101.5°F (40.1°C)." Which instruction should the nurse provide until the patient can be seen by the healthcare provider? A. Increase fluids. B. Alternate doses of an antipyretic and anti-inflammatory. C. Take an antipyretic every hour. D. Stay under a blanket.
Answer: A A fever causes an increase in insensible water loss from sweating. Dehydration is a particular concern in older adults and treatment includes increasing oral fluids. Hourly doses of acetaminophen could lead to an overdose. There is research supporting that alternating doses of acetaminophen with ibuprofen has no effect in children. This approach has not been studied in older adults and should not be recommended. A blanket would cause the body to retain heat and cause an increase in temperature.
During a home visit, the nurse becomes concerned with the care a 6-year-old child with fever is receiving from the parent. Which action performed by the parent should concern the nurse? A. Providing the child with aspirin B. Providing the child with acetaminophen C. Encouraging the child to drink more fluids D. Applying topical medication to reduce itchiness from a rash
Answer: A Acetylsalicylic acid, or aspirin, should be avoided in children under the age of 18 due to the increased risk of developing Reye syndrome, particularly in children with the flu virus and varicella infections. Encouraging fluids is a positive measure. Acetaminophen is the recommended initial antipyretic in children. Applying topical medication to reduce itchiness is a positive measure.
After rewarming the feet, the nurse elevated the feet on pillows. The patient asks, "Why are you putting my legs on pillows?" Which statement by the nurse is correct? A. "This will promote better circulation to your legs and feet." B. "The pillows will help keep your legs warm." C. "This will prevent cold blood from returning to the rest of your body." D. "You will be more comfortable with your legs on a pillow."
Answer: A After rewarming, the nurse should elevate the affected extremities to increase blood flow, not to restrict cold blood from returning to the rest of the body. While the patient may be more comfortable with their extremities elevated, the main reason for doing so is to promote circulation to the lower extremities. The purpose of elevating the extremities is not to keep the legs warm.
The nurse is conducting a teaching session with a group of college students regarding alcohol consumption and the risk of hypothermia. Which information should the nurse include in the teaching? A. Alcohol causes peripheral vasodilation, which increases the rate of cooling. B. Alcohol impacts respiratory function, which contributes to hypothermia. C. Alcohol causes peripheral vasoconstriction, which increases the rate of cooling. D. Alcohol impacts sensory perception and the individual's ability to sense cold.
Answer: A Alcohol causes vasodilation, leading to an increased rapid rate of cooling. Some medications impact sensory perception, circulation, thermoregulation, and respiratory function, which contribute to hypothermia. However, this is not directly associated with alcohol use.
The nurse is assessing a patient recovering from severe hypothermia and notes black tissue on the patient's toes. Which collaborative intervention should the nurse anticipate? A. Preparing the patient for surgical debridement of the toes B. Placing warm blankets on the patient's toes C. Rewarming the toes in a water bath at 107.6°F (42°C) for 30 minutes D. Rewarming the toes using active internal rewarming
Answer: A Black tissue indicates that the tissue is necrotic and must be removed to prevent infection. The patient will need surgical excision and debridement. It is too late to rewarm the toes or apply warm blankets. Active internal rewarming is used to warm the core, not the extremities.
The nurse is planning care for a patient who has a baseline body temperature of 38.7°C (101.6°F). After assessment, the nurse assigns the nursing diagnosis of Fluid Volume: Deficient, Risk for. Which rationale explains the selection of this nursing diagnosis? A. Hyperthermia increases metabolism, which results in the need for fluid. B. Febrile seizures due to severe hyperthermia can cause fluid losses. C. Vasoconstriction from hyperthermia causes fluid losses to occur. D. Tachycardia causes a decrease in blood volume, leading to dehydration.
Answer: A Hyperthermia increases metabolism due to insensible water losses from sweating and tachypnea. Dehydration occurs faster in younger children and older adults due to body water composition. It is important to increase fluid intake by at least 2000 mL per day when a fever is present. Vasodilation, not vasoconstriction, leads to facial flushing and warmth. Tachycardia occurs from an increased metabolic rate. Febrile seizures do not cause fluid volume losses; they result from hyperthermia.
The nurse is assessing a patient who is critically ill with suspected hypothermia. Which site should the nurse use to take the temperature? A. Esophagus B. Temporal artery C. Rectum D. Tympanic membrane
Answer: A It is important for the nurse to take a true core temperature, which can be obtained from the esophagus, pulmonary artery, or bladder. The rectum, tympanic membrane, and temporal artery also measure the core temperature, but these sites are not as accurate.
A patient who is scheduled for surgery tells the nurse, "I do not respond well to anesthesia and get really hot." Which action should the nurse take first? A. Notify the surgeon. B. Review the patient's white blood cell count. C. Suggest that the surgery be cancelled at this time. D. Document the comment in the medical record.
Answer: A Malignant hyperthermia is an inherited disorder that affects temperature regulation. It causes a serious reaction to inhaled anesthetic gases and depolarizing neuromuscular blockers, leading to extremely high temperature elevations. There is a 35% morbidity rate with malignant hyperthermia. The nurse needs to notify the surgeon of the patient's comment. The patient's white blood cell count is not going to help determine if their temperature will rise again with anesthesia. The nurse should document the finding in the medical record after contacting the surgeon. The surgeon will decide whether to cancel the surgery.
The nurse is caring for a patient who is undergoing core rewarming after extreme cold exposure. The patient is still hypothermic, despite efforts to warm them up. The nurse should ask the patient's relatives about a history of which medical condition? A. Hypothyroidism B. Hyperthyroidism C. Diabetes D. Heart disease
Answer: A Patients who fail to rewarm may have hypothyroidism, and the nurse should ask the patient's relatives about a history of this condition. Medication list, medical history, and surgical scars can also provide information about potential hypothyroidism. Hyperthyroidism, diabetes, and heart disease do not impact a patient's ability to rewarm following hypothermia.
The nurse is caring for a patient recovering from hypothermia. Which outcome should the nurse expect? A. The patient is able to list early signs and symptoms of hypothermia. B. The patient develops piloerection. C. The patient states the need to take antipyretics at the first sign of a fever. D. The patient's core temperature rises to 101.8°F (38.8°C).
Answer: A Reporting early signs and symptoms of hypothermia is an expected outcome for a patient with hypothermia. Other expected outcomes include no piloerection or shivering, ability to maintain core temperature within normal ranges, and reporting thermal comfort. Antipyretics are not used in hypothermia.
The nurse is teaching the parents of a child about fever management. The parents ask about alternating acetaminophen with ibuprofen. Which response by the nurse is accurate? A. "Evidence shows that there is no improvement in condition with alternating acetaminophen and ibuprofen." B. "I hope you do not want to alternate these medications to get the child back to school faster." C. "That is a good idea. Make sure you follow the recommended dosing on the drug insert." D. "You should try using aspirin for fever and pain relief for your child."
Answer: A Research has shown that alternating doses of acetaminophen and ibuprofen does not shorten the course of the cause of the fever. The nurse should not inform the parent it is a good idea, but it is appropriate to instruct the parent to follow the directions for dosing on the drug insert. Asking the parents if they want to alternate ibuprofen and acetaminophen to get the child back to school faster is not therapeutic communication. The nurse would not suggest that the parents use aspirin in children with fevers, because aspirin can cause Reye syndrome.
The parent of a 6-year-old child with a fever calls the nurse to report that the child will not drink water to replace fluid losses. Which instruction should the nurse give the mother? A. Provide extra fluids with popsicles and flavored gelatin. B. Encourage the consumption of milk and milk products with ice cream and yogurt. C. Bring the child to the emergency department for intravenous fluids. D. Explain to the child the need for drinking a lot of water.
Answer: A Since it is difficult to encourage younger children to drink water, instruct the parents to provide the fluids in ways the child will enjoy. This includes the use of popsicles and sports drinks. Encouraging fluids to replace losses from increased metabolism and fever is important. There is no evidence that the child needs to be brought to the emergency department. Younger children are stubborn and, when ill, would not understand the importance of increasing water intake. Milk and milk products do not provide fluids, nor do they help with fluid balance.
The nurse is assessing a patient with a fever. Which other clinical manifestation should the nurse expect to find? A. Tachycardia B. Hyperglycemia C. Hypotension D. Bradypnea
Answer: A Tachycardia is the body's way to correct the temperature elevation by increasing the metabolic rate. This causes the pulse rate to increase. An increase in oxygen demand causes tachypnea. The illness itself may cause slight hyperglycemia, but this would not be related to the fever. Fluid volume losses lead to hypotension, not a fever.
A client with a fever is admitted for dehydration. Which information should the nurse use to help determine the cause of this client's fever? (Select all that apply.) A. Client age B. Health history C. Amount of alcohol ingested daily D. History of substance use E. Employment status
Answer: A, B Rationale: The amount of collaborative care for a client with hyperthermia will depend on the underlying reason for the fever. This includes studying the client's age and health history. Employment status, history of substance use, and amount of alcohol ingested are areas within the client's lifestyle and do not necessarily impact the client's health history.
The nurse is caring for a 5-year-old child with a fever, nausea, vomiting, and seizures. Which information should the nurse provide the parents to alleviate their fears? A. "Because of your child's age, it is less likely that your child will have additional seizures." B. "Have you or anyone in your family, including your child, ever had seizures before?" C. "Research shows children who experience febrile seizures will develop a seizure disorder." D. "An electroencephalogram (EEG) can be done to determine brain damage."
Answer: A The best way to alleviate fears is to provide information to the parents. The nurse should explain that the older the child is at the onset of seizures, the less likely the child will have seizures later in life. An EEG detects abnormal brain waves, not febrile brain damage. Research shows that one-third of children who have febrile seizures grow up to have a seizure disorder.
The mother of a preschool-age child is concerned because the child became normothermic after receiving a dose of acetaminophen but, 4 hours later, is febrile again. Which instruction should the nurse give the mother? A. Provide another dose of acetaminophen. B. Give the child a cold bath. C. Give a dose of aspirin. D. Take the child to the nearest emergency department.
Answer: A The child's temperature may rise again 4 hours after receiving acetaminophen. The mother should check the temperature and give another dose of acetaminophen. Alternating acetaminophen with ibuprofen when treating fevers in children is not recommended. Children should not be given aspirin due to the risk of Reye syndrome. A cold bath could cause chilling in the child. The child does not need to be taken to the emergency department.
Which adult body temperature should the nurse reassess and report to the healthcare provider? A. 39°C (102.2°F) B. 37.5°C (99.5°F) C. 37°C (98.6°F) D. 36°C (96.8°F)
Answer: A The normal adult temperature ranges between 36° and 38.5°C. The nurse should reassess the patient and notify the healthcare provider if the temperature is 38.5°C (101.3°F) and above. Temperatures between 36°C (96.8°F) and 37.5°C (99.5°F) are within the normal range.
The nurse is developing a plan of care for a child admitted to the hospital for a fever. Which nursing intervention should the nurse include in the plan of care? A. Giving a tepid sponge bath after administering fever medication B. Applying warm washcloths or ice bags to the axilla, groin, and forehead C. Having the child wear an extra layer of clothing D. Providing 1000 mL of fluid intake within a 24-hour period
Answer: A The nurse should include tepid sponge baths after administering an antipyretic in the plan of care to reduce body temperature and increase the child's comfort. The nurse would apply cool washcloths or ice bags to the groin, axillae, and forehead. Fluid intake should be at least 2000 mL/24 hours to replace fluid lost through perspiration and fevers. The child should wear loose-fitting clothing to prevent heat and sweat from being trapped.
The nurse is completing the health history for a newly admitted patient diagnosed with hypothermia. Which should the nurse identify as the most important health history data to assess? A. Medications B. Blood pressure C. Skin color D. Heart rate
Answer: A The patient's current medication regimen will be considered during the health history aspect of the nursing assessment for a patient with hypothermia. Skin color, blood pressure, and heart rate will be considerations of the physical exam of the nursing process.
While the nurse is preparing to assess a child's temperature, the parents report that the child had ear tubes placed last year. Which site should the nurse understand is contraindicated in this patient? A. Tympanic membrane B. Rectal C. Axillary D. Oral
Answer: A The presence of ear tubes or a suspected ear infection is a contraindication for using the tympanic membrane to measure temperature. The oral, rectal, and axillary routes are appropriate to measure this child's temperature.
The nurse assessing an 18-month-old decided not to use a tympanic thermometer. Which assessment finding led to this nursing decision? A. Presence of ear drainage tubes B. Presence of a total body rash C. Finding of irritability and crying D. Occurrence of projectile vomiting
Answer: A The tympanic route should be avoided in a child with an active ear infection or tympanic membrane drainage tubes. A body rash, projectile vomiting, and crying and irritability are not contraindications for the use of the tympanic membrane for temperature measurement.
The nurse is teaching a patient on how to prevent fluid imbalance while experiencing an elevated temperature. Which instruction should the nurse include in the teaching? A. Drink at least 2 L of cool fluids each day. B. Wear sufficient clothing to encourage sweating. C. Take a hot shower after spending time outdoors. D. Ingest at least 1 L of hot fluids each day.
Answer: A To maintain fluid balance during a fever, the nurse should instruct the patient to drink at least 2 L of cool fluids each day. Ingesting warm fluids will not help maintain fluid balance during a fever. Wearing clothing to cause sweating could increase insensible fluid loss and contribute to a fluid imbalance during a fever. Taking a hot shower after spending time outdoors could cause the patient's temperature to rise and further increase insensible water loss.
The nurse is caring for a client who has a systemic infection. Which action should the nurse perform to limit the spread of this infection? A. Performing effective hand hygiene B. Evaluating fluid balance C. Providing antipyretics as prescribed D. Monitoring electrolyte status
Answer: A Rationale: Actions to prevent the spread of infection include performing effective hand hygiene. Evaluating fluid balance and monitoring electrolyte status would be applicable if the fever were impacting the client's fluid and electrolyte balance. Providing antipyretics as prescribed would ensure for the client's comfort.
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. "Body temperature in an older adult is not a reliable indicator of the seriousness of an illness." B. "Your body temperature fluctuates significantly, so a true temperature is difficult to obtain." C. "The true temperature will not register because you are a mouth breather." D. "I will to take your temperature rectally, since it is the only reliable route in somebody your age."
Answer: A 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.
The nurse provided teaching to the parents of a young child who was treated for febrile seizures. The nurse provided information on how to care for the child at home. Which statement by the parents indicates effective learning? A. "I should administer an antifever medication once my child's temperature goes above 101°F (38.33°C)." B. "I should implement seizure precautions as soon as my child's temperature starts to go up." C. "I need to bring my child into the emergency department as soon as the temperature is above 99°F (37.22°C)." D. "My child is not likely to have a second febrile seizure."
Answer: B A child who has had a febrile seizure is at risk for having another one. The parent should immediately treat any fever with antipyretic medications and watch the child closely for signs of another febrile seizure. It is not necessary to bring the child into the emergency department for a fever above 99°F (37.22°C).
A patient tells the nurse, "I feel warmer after I walk in the hall." Which response by the nurse is accurate? A. "The walk might have been too much for you to do at this time." B. "Walking uses the muscles, which produces heat." C. "I'll check your temperature to make sure you aren't coming down with a fever." D. "Heat from the environment is making you feel hot."
Answer: B All muscle activity produces heat and increases the metabolic rate. This is why the patient feels warmer after walking down the hall. The patient is not feeling warmer because of the environment. Feeling warmer after a walk does not mean that the exercise was too much for the patient to do at this time. The patient feeling warmer does not mean that the patient is coming down with a fever.
A child presents to the clinic with a fever of 38.4°C (101.1°F). The nurse should suspect which condition as being the most likely cause of the child's fever? A. Sunburn B. Infection C. Dehydration D. Overactivity
Answer: B An infection is the most common reason for a fever in a child. Common infections in children that can cause a fever include common cold gastroenteritis, ear infections, croup, bronchiolitis, and urinary tract infections. Sunburn, dehydration, and overactivity are not the most common reasons for a fever in a child.
Which patient should the nurse identify as having the greatest risk for hypothermia? A. A 3-year-old B. A 3-day-old infant C. A 15-year-old D. A 45-year-old
Answer: B Full-term newborns lose about four times more heat than adults due to their large body surface in relation to mass and a limited amount of insulating subcutaneous fat. Older adults may also be more sensitive to temperature changes due to a loss of subcutaneous fat. It is not expected for a 3-year-old, a 15-year-old, or a 45-year-old to have decreased subcutaneous fat.
The daughter of an 86-year-old man is concerned because her father is always complaining about being cold. Which statement by the nurse explains temperature regulation to the patient's daughter? A. "There is less body fat and the blood vessels are closer to the skin in an older adult." B. "Older adults are less efficient at regulating their body temperature." C. "Older adults are homeothermic, stabilizing the core body temperature within a narrow range." D. "Extremes in environmental temperature are well tolerated by older adults."
Answer: B Older adults can be at risk for hypothermia because of less efficient thermoregulation. This causes older adults to be sensitive to extremes in environmental temperatures. Newborns are homeothermic, which means that the body stabilizes the core body temperature within a narrow range. Newborns have less subcutaneous fat, and their blood vessels are closer to the skin. Children, not adults, tolerate extremes in environmental temperature.
The parents of a child with a fever call the nurse and report purple spots on the child's extremities. Which response by the nurse is appropriate? A. "Those spots will go away in a few days after the fever subsides." B. "You should bring the child to the emergency department for evaluation." C. "Give your child aspirin as directed on the bottle for the fever symptoms." D. "Come see the healthcare provider if the fever lasts 4 or more days."
Answer: B Purplish spots on the legs in conjunction with a fever should be assessed due to possible leukemia. Children should never be given aspirin with a fever, because this can cause Reye syndrome. Purplish spots on the skin in the presence of a fever should not be ignored for 4 days before healthcare provider intervention.
The nurse is caring for a child after a sledding injury. The nurse suspects the child has superficial frostbite. Which assessment finding supports the nurse's suspicion? A. Hallucinations B. White appearance of the tip of the nose C. Yellow appearance of the tip of the nose D. Presence of gangrene
Answer: B Superficial frostbite causes a white, cyanotic, or reddened appearance of affected areas. A yellow appearance, hallucinations, and presence of gangrene occur with deeper frostbite.
The nurse suspects that an older adult patient with hypothermia is unable to maintain an adequate temperature at home due to financial problems. Which intervention is most appropriate for this patient? A. Contact the patient's utility company. B. Suggest a medical social worker see the patient. C. Contact adult protective services. D. Suggest a representative from financial services see the patient.
Answer: B The nurse should suggest that a medical social worker see the patient to assess the patient's ability to maintain a safe environment at home. A representative from the hospital's financial services usually deals with hospital finances, not the patient's finances at home. Contacting adult protective services or the utility company prior to social worker assessment is inappropriate.
The parents call the clinic to report that their 5-year-old child has a temperature of 40.1°C (104.2°F). In which instance should the nurse instruct the parents to take their child to the emergency department? A. Intermittent crying B. Neck stiffness C. Nasal congestion D. Increased sleeping
Answer: B The nurse would instruct the parents to take the child to the emergency department if the neck is stiff. Nuchal rigidity (stiff neck) is a sign of meningitis and needs immediate evaluation. Intermittent crying is acceptable; continuous, inconsolable crying would require an emergency department visit. Many people sleep more when they are sick; if the parents have difficulty waking the child up, this would necessitate an emergency department visit. Nasal congestion can be from a respiratory virus or allergies.
An unresponsive patient is brought into the emergency department after being found outside in the cold. Which is the priority intervention by the nurse? A. Assessing the patient's skin for frostbite B. Assessing respiratory status, oxygenation, and perfusion C. Hanging warmed intravenous fluids D. Applying warming blankets
Answer: B The priority intervention by the nurse is to assess respiratory status and how effective the patient is oxygenating and perfusing. If the patient is not breathing or does not have a heartbeat, the nurse must implement cardiopulmonary resuscitation (CPR) and initiate the code team as per hospital policy. Assessing for frostbite is an important intervention but not until it is determined that the patient is breathing appropriately. Application of warming blankets or instillation of warmed intravenous fluids may be ordered by the healthcare provider but are not the priority for the nurse.
The nurse provided teaching to the parents of a 7-year-old child about antipyretics. Which statement by the parent indicates that learning has occurred? A. "I will call the healthcare provider before giving acetaminophen to my child." B. "I will not give aspirin or any other medication with aspirin in it to my child." C. "I will give my child ibuprofen on an empty stomach." D. "I will only use acetaminophen to reduce swelling from now on."
Answer: B Rationale: Acetylsalicylic acid (ASA), or aspirin, is contraindicated in children under the age of 18 due to the risk of Reye syndrome. This is especially important in children with a suspected viral infection, such as the flu or varicella. Ibuprofen is given with food or a full glass of water to decrease gastric irritation. Acetaminophen is used for pain or fever, not inflammation. Acetaminophen may be given to a 7-year-old without an order from the healthcare provider.
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
Answer: B 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, 32-35°C (89.6-95°F); moderate, 28-32°C (82.4-89.6°F), orsevere, below28°C (less than82.4°F). The usual range of core body temperature is called normothermia. The normal range for adults is between36°C and38.5°C (96.8°F and101.3°F). Malignant hyperthermia is a potentiallyfatal, inherited disorder that results from thebody's reaction to volatile inhalation of anesthetic gases andsuccinylcholine, a depolarizing neuromuscular blocker.
The nurse provided teaching to the parent of a newborn about thermoregulation. Which statement by the parent indicates that learning has occurred? A. "I should use an oral thermometer whenever I take the baby's temperature." B. "I should put a hat on my baby to prevent heat loss through the head." C. "I should report a temperature greater than 102°F to the doctor." D. "I should avoid bathing the baby for at least 6 weeks."
Answer: B Rationale: Young infants are at higher risk for heat loss through their heads, so it is important for them to wear hats. It is not necessary to avoid bathing the baby. Any fever in a newborn should be reported to the healthcare provider, not just a temperature greater than 102°F. An oral thermometer is not appropriate for a newborn infant because the baby is not able to keep the thermometer in place and it could possibly cause injury to the baby's mouth.
Which is a noninvasive method that the nurse uses to assess a client's temperature? (Select all that apply.) A. Tympanic membrane B. Axillary C. Temporal artery D. Oral E. Rectal
Answer: B, C Rationale: The two methods of measuring temperature that are safe and noninvasive are the axillary method and temporal artery. The client could bite down during the oral approach and damage sensitive oral mucosa. The rectal method is invasive and could damage sensitive tissue. Although generally safe, the tympanic temperature measurement is an invasive procedure.
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. Shivering D. Sleepiness E. Thirst
Answer: B, C 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.
A patient recovering from a foot wound is resting comfortably in bed. During the last vital signs assessment, the patient's temperature was 37.5°C (101.7°F). Which action should the nurse implement? A. Give the patient a tepid sponge bath. B. Apply an ice pack to the groin. C. Document the assessment results. D. Provide a cooling blanket.
Answer: C A low-grade fever that is under 38.3°C (101°F) in an adult may not be treated unless the patient is experiencing discomfort; however, it still needs to be documented. Since the patient is resting comfortably in bed and has a temperature of 37.5°C (101.7°F), no treatment is indicated. A cooling blanket, tepid sponge bath, and ice pack to the groin would be indicated if the patient's temperature were higher than low grade.
The nurse notes that a patient experiencing hyperthermia drank 40 oz of fluid during the previous 24 hours. Which collaborative action should the nurse expect to implement? A. An antipyretic B. A tepid sponge bath C. Intravenous fluids D. A cooling blanket
Answer: C Actions to ensure fluid balance in a patient experiencing hyperthermia include encouraging an oral fluid intake of at least 2 L per day. If oral fluids are insufficient, intravenous fluids should be provided. Since the patient's oral fluid intake was less than 2 L (40 oz = 1200 mL), the nurse should prepare to begin intravenous fluids for the patient. A cooling blanket, acetaminophen, and a tepid sponge bath are not interventions to ensure fluid balance in the patient experiencing hyperthermia.
The nurse is caring for four patients. Which patient should the nurse assess as having the highest risk for developing hyperthermia? A. A 45-year-old adult with uncontrolled diabetes mellitus B. A 20-year-old adult with an asthma exacerbation C. A 4-month-old child with respiratory syncytial virus D. A 60-year-old adult with congestive heart failure
Answer: C Due to changes in water composition in the very young and old, patients in these age groups are at higher risk for hyperthermia. Therefore, the 2-month-old child with respiratory syncytial virus can have a raised temperature, adding to fluid losses. An asthma exacerbation causes shortness of breath. Diabetes mellitus would cause hyperglycemia. A patient with congestive heart failure has fluid volume overload.
A patient with head trauma has been admitted with hypothermia. Which observation should lead the nurse to expect hemodialysis will be ordered to treat this patient? A. Damage to the vascular system B. Damage to the blood C. Damage to the hypothalamus D. Damage to the renal system
Answer: C Hemodialysis is typically used when hypothermia occurs with damage to the hypothalamus (as in trauma or stroke). Damage to the renal system and damage to the vascular system or the blood are not primary reasons hemodialysis would be used in the treatment of hypothermia.
The nurse is teaching a new parent about how to avoid hypothermia in their infant. Which statement by the parent indicates to the nurse that teaching was effective? A. "I will feed my baby every 3 hours to prevent them from getting too cold." B. "If my baby feels cool, I will take them outside into the sun." C. "I keep my baby wrapped in a blanket and hat when we go outside." D. "If my baby is cold, I will know it because they will shiver."
Answer: C Minimizing heat loss is the best method of avoiding hypothermia in infants. Full-term newborns lose about four times more heat than adults due to the relatively large surface area in comparison to the mass of their bodies and the lack of insulating subcutaneous fat. Thermal conduction is a risk because the infant cannot adequately respond to the air's cooler temperature. One mechanism of heat production is chemical thermogenesis (nonshivering thermogenesis), which utilizes brown adipose tissue to provide heat. Sun exposure is not advised for infants.
A college student, brought to the emergency department by his girlfriend, has a body temperature of 94.8°F (34.9C). Which question is most important for the nurse to ask the girlfriend to help determine the patient's condition? A. "When did you find him?" B. "Where did you find him?" C. "Was he drinking alcohol?" D. "How long was he outside?"
Answer: C Modifiable risk factors for the development of hypothermia include ingestion of alcohol and other substances. The nurse needs to learn if the patient was drinking alcohol. The location of the patient, the time the patient was found, and the length of time the patient was exposed to the elements are not as important as knowing whether the patient has ingested alcohol.
The nurse is teaching a patient how to take a nonsterioidal anti-inflammatory drug (NSAID). Which instruction should the nurse provide? A. Take it on an empty stomach first thing in the morning. B. Take it 1 hour before checking temperature at home. C. Take it with food or a full glass of water. D. Take it 2 hours after each meal.
Answer: C NSAIDs should be taken with food or a full glass of water to decrease gastric irritation. Taking it 2 hours after meals could cause gastric irritation. Taking it on an empty stomach could lead to gastric irritation. There is no reason to take the medication 1 hour before checking the temperature.
A patient with a body temperature of 39.0°C (102.2°F) asks the nurse, "Can you do something about my mouth being so dry?" Which intervention should the nurse implement to maximize the patient's comfort? A. Suggesting that the healthcare provider order a fluid restriction B. Allowing the patient to go outside to smoke once per shift C. Assisting the patient in performing oral hygiene D. Giving the patient lemon glycerin swabs to swab lips
Answer: C Oral hygiene helps to moisten the mouth in addition to preventing infection and mucous membrane breakdown (mouth sores). Lemon glycerin swabs often have alcohol in them, which is very drying to the mucous membranes. Smoking and tobacco are both drying and irritating to the mucous membranes.
The school nurse is giving a presentation for parents regarding hypothermia. Which statement should the nurse include regarding the first step in treating hypothermia? A. "Have your child take a warm whirlpool bath." B. "Remove clothing and assess for frostbite after a day playing in the snow." C. "Provide dry clothing and warm blankets when your child comes in from outside." D. "Immediately administer anti-inflammatories to warm up your child."
Answer: C Rewarming the child is the first priority. Removing the clothing would not warm the patient. Anti-inflammatories and whirlpool therapy would be administered for severe hypothermia. Other interventions for moderate hypothermia include keeping limbs close to the body, using a hat or cap to cover the top of the patient's head, supplying warm oral or IV fluids, and applying warming pads.
The nurse is taking report for a group of patients. The nurse anticipates that which patient will need surgical debridement? A. A hyperthermic athlete who passed out at practice yesterday B. An older adult patient who has a fever of unknown origin C. A patient who is hypothermic and has black tissue on the tip of their nose D. A young child who has had a fever of 104.5°F (40.3°C) for 3 days
Answer: C Surgical debridement is used to remove dead or necrotic tissue before it spreads or causes infection. The patient with black tissue on the tip of the nose is most likely to need surgical debridement. A hyperthermic athlete, young child with a fever, or an older adult patient with a fever of unknown origin do not require surgical debridement.
The nurse is planning care for a patient with hypothermia. Which independent nursing intervention is appropriate? A. Obtain the blood glucose level. B. Order a social worker referral. C. Administer warm oral fluids. D. Administer warm IV fluids.
Answer: C The nurse should administer warm oral fluids to the patient. The nurse cannot order a social worker referral but can suggest it to the ordering healthcare provider. Obtaining the blood glucose level and administering warm IV fluids are dependent, not independent, nursing interventions.
A patient presents with frostbite to the left ear, nose, and feet. Which intervention should the nurse implement? A. Massage affected areas to increase blood flow. B. Place affected areas in the dependent position. C. Avoid handling affected areas after rewarming. D. Protect and cover any blisters.
Answer: C The nurse should avoid handling affected areas after rewarming to avoid further tissue damage. The nurse should elevate affected areas and avoid massage or rubbing to prevent further tissue damage. Blisters if present, should be debrided, not covered.
The nurse comes upon an older adult patient outside their home who has collapsed, is not wearing a coat, and feels cool to the touch. The temperature outside is cool with a chilly breeze. Which is the priority intervention for the nurse? A. Begin cardiopulmonary resuscitation (CPR) immediately. B. Place a hat on the patient's head. C. Place a warm towel or warm plastic bottle on the patient's trunk. D. Apply hand warmers to the patient's hands and arms.
Answer: C Use warm compresses, if available, or a warm towel or warm water in a plastic bottle to warm the patient's core. Apply to the patient's neck, chest, and groin. Avoid placing on the extremities, because this will increase circulation of cold blood to the patient's organs and core, further decreasing core temperature. Avoid direct heat due to the potential for skin damage and dysrhythmias. If the patient is conscious, responsive, and able to swallow, offer warm high-calorie liquids. Only begin CPR if the patient is not breathing or does not have a pulse.
The mother of a 13-day-old newborn calls the nurse in the clinic and reports that the newborn has an axillary temperature of 101.8°F. Which intervention should the nurse suggest to the mother? A. Put the newborn in warm clothing while the fever is present. B. Take the temperature again orally after giving the newborn a cold bath. C. Bring the newborn to the emergency department for evaluation. D. Administer acetaminophen and call back if the fever does not go away.
Answer: C Rationale: Any newborn younger than 4 weeks old with a fever should be admitted to the hospital for further evaluation and testing. It is not appropriate for the nurse to suggest just giving the baby a cool bath or administering acetaminophen or ibuprofen.
The nurse is working on a committee to develop emergency department policies for the administration of antipyretics. Which should be included? A. Admit the client to the hospital if a second dose of an antipyretic is required. B. Avoid antipyretics until clients are admitted to the hospital. C. Administer antipyretics as soon as possible. D. Wait until a fever reaches 101°F before administering an antipyretic.
Answer: C Rationale: In all ages, antipyretics should be administered as soon as possible after the client enters the emergency department. It is important for the staff to remember that, if the fever is successfully treated with antipyretics, there may still be an infection present. It is not appropriate to admit the client to administer an antipyretic or because a second dose of an antipyretic medication is required.
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. Encourage the school to move athletic activities indoors. B. Reduce athletic activities at the school. C. Increase access to fresh, cold water. D. Cancel athletic games when the temperature is above 80°F.
Answer: C 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.
The nurse is at a party when a guest faints due to suspected hyperthermia. What should the nurse do first? A. Remove clothing and lightly mist the guest with cool water. B. Help the guest get inside, and call 911. C. Send someone to call 911 and stay with the guest. D. Run inside and call 911.
Answer: C Rationale: It is important for the nurse to stay with the client until help arrives. The nurse should send another guest to call for help. The nurse should remove as much clothing as possible, lightly mist the client with water, and move them into an air-conditioned or cool, shaded area while waiting for the ambulance.
The nurse is preparing information at a community health fair about safety during hot weather. Which information should the nurse include? (Select all that apply.) A. Spend time outdoors during the hours of 10 a.m. and 2 p.m. B. Limit the intake of alcohol to the end of the day. C. Drink fluids throughout the day. D. Wear a hat. E. Drink extra fluids when exercising or working out of doors.
Answer: C, D, E Rationale: Actions to ensure thermoregulation during hot weather include wearing a hat, drinking an adequate amount of fluids, and drinking extra fluids when exercising. Alcohol is not recommended for use during hot weather. The sun is hottest between the hours of 10 a.m. and 2 p.m.; being outside during those hours may promote heat-related illnesses.
The nurse is assessing a child with a history of febrile seizures and notes that the child has a temperature of 101.2°F (38.4°C). How should the nurse proceed? A. Prepare to administer acetaminophen once the temperature reaches 102°F (38.4°C). B. Monitor temperature every 4 hours. C. Insert a Foley catheter to monitor urine output. D. Implement seizure precautions.
Answer: D A child with a history of febrile seizures is likely to have another one. The nurse should implement seizure precautions immediately, inform the healthcare provider, and administer antipyretics as ordered. It is not appropriate for the nurse to monitor the temperature only every 4 hours, as the fever could go up rapidly in that time frame. Inserting a Foley catheter to monitor urine output is not appropriate (especially with a urinary tract infection) or needed for this child.
The nurse is caring for a young child who has been hospitalized for a week with a fever of unknown origin. During this morning's vital signs evaluation, the nurse notes that the child has a temperature of 37.5°C (99.5°F). Which is the nurse's priority intervention? A. Placing ice packs in the armpits and groin B. Administering antipyretics as ordered C. Informing the healthcare provider D. Documenting the finding as normal
Answer: D A temperature of 37.5°C (99.5°F) is considered to be a low-grade fever. The nurse only needs to document the finding and continue to monitor the child's temperature. There is no need to inform the healthcare provider, administer antipyretics, or place ice packs in the child's armpits or groin.
A graduate nurse is planning care for a patient diagnosed with hypothermia and frostbite. The preceptor asks, "Which intervention is performed after rewarming the patient's feet?" Which statement by the graduate nurse indicates understanding of the next intervention? A. "I should rub the patient's legs with lotion." B. "I should have the patient dangle the legs off the side of the bed." C. "I should place compression stockings on the patient's legs." D. "I should elevate the patient's legs on pillows."
Answer: D After rewarming, the nurse will elevate the affected extremities to increase blood flow, not place extremities in the dependent position (off the side of the bed). The nurse will not compress or rub the affected extremities, because this can further damage tissues.
The nurse is talking with a hospitalized older adult patient who reports "feeling chilly." The nurse suggests walking in the halls. What is the nurse's rationale for making the suggestion? A. Walking can distract the patient from their discomfort. B. The hallways are warmer than the patient's room. C. Walking helps to strengthen muscles, which, over time, will increase thermoregulation. D. Walking uses the muscles, which produces heat and can help to warm the patient.
Answer: D All muscle activity produces heat and can help the patient to warm up. This is why the nurse suggests that the patient go for a walk down the hall. The patient will not immediately warm up because of increased hall temperature, distraction, or long-term muscle gain.
The nurse is evaluating the outcome of care provided to a patient who developed a postoperative fever. Which outcome indicates that care has been successful? A. The patient's temperature spikes occur only during the night. B. The patient's heart rate is 100 beats/min, and respirations are 28 breaths/min. C. The patient appears flushed and the skin is warm to the touch. D. The patient's body temperature is 98.4°F (36.9°C) without the use of antipyretics.
Answer: D Evidence that interventions to reduce a fever were effective would be the patient having a normal body temperature without the use of antipyretics. A heart rate of 100 beats/min and respiratory rate of 28 breaths/min indicate that the patient's metabolic rate is still being affected by the fever. Temperature spikes indicate that the fever is still present. Flushed and warm skin indicates that the patient is still experiencing a fever.
The nurse is teaching a group of hikers about the signs of heatstroke. Which signs should the nurse include? A. Body temperature alternating between periods of fever and periods of normal or subnormal temperature. B. Fluctuating temperatures of more than 2°C (5.3°F) above normal within 24 hours C. Paleness, dizziness, nausea, vomiting, fainting, with a temperature of 38.5°C (101.3°F) D. Warm, flushed skin without sweating and a temperature of 41.1°C (106°F) or higher
Answer: D Heatstroke can happen from exposure to high temperatures and dehydration. The nurse would instruct the hikers that the signs include warm, flushed skin, usually without sweating. The body temperature can get as high as 41.1°C (106°F) or higher. Heat exhaustion involves paleness, dizziness, nausea and vomiting, faintness, and a lower body temperature than heatstroke, ranging from 38.3°-38.9°C (101°-102°F). A remittent fever is when the person has a range of fluctuating temperatures more than 2°C (5.3°F) above normal within 24 hours. An intermittent fever is when the person experiences variations of body temperatures, some elevated, some normal, and some subnormal.
The nurse is teaching a new parent about how to protect their infant from hypothermia. Which statement by the parent indicates that further teaching is needed? A. "I will make sure I keep my baby warm and dry at all times." B. "If my baby feels cool, I will wrap them in a warm blanket." C. "If my baby feels cool, I will place a hat on their head." D. "If my baby feels cool, I'll place them in direct sunlight with as much skin exposed as possible."
Answer: D Minimizing heat loss is the best method of avoiding hypothermia in infants. Full-term newborns lose about four times more heat than adults due to the relatively large surface area in comparison to mass of their bodies and the lack of insulating subcutaneous fat. Thermal conduction is a risk because the infant cannot adequately respond to the air's cooler temperature. One mechanism of heat production is chemical thermogenesis (nonshivering thermogenesis), which utilizes brown adipose tissue to provide heat.
An older adult patient presents with mild hypothermia and has been initially treated with blankets and forced warm air. Which intervention should the nurse expect to implement next? A. Massage the patient's extremities. B. Encourage the patient to ambulate. C. Administer whirlpool therapy. D. Administer warm IV fluids.
Answer: D Patients with moderate-to-severe hypothermia and older adults with mild hypothermia require active external rewarming (AER), which entails using several rewarming methods concurrently: warm blankets, radiant heat, warm bath, forced warm air, and warm IV fluids. Rubbing or massaging the patient's extremities is not appropriate. Whirlpool therapy is used to debride necrotic tissue. Patients with hypothermia should be on bedrest.
The nurse is teaching a patient how to treat mild hyperthermia. Which nonpharmacologic action should the nurse include? A. "Avoid turning on a fan, because it could spread germs." B. "You should eat warm foods, like chicken broth." C. "You can take a cold bath every 4 hours to cool down." D. "You should remove any extra clothing or blankets."
Answer: D Removing any extra clothing or blankets is necessary for the febrile patient's body to cool down. The hot and cold theory says that eating cold foods will help if febrile and that eating hot foods will help if chilled. Tepid, not cold, baths are recommended. Turning on the fan will help the patient cool down and will not spread the pneumonia. Pneumonia is transmitted through droplets when the patient coughs in close vicinity to another person.
Which nonpharmacologic intervention should the nurse include in the plan of care to promote normal body temperature in a patient with a fever? A. Placing multiple blankets on the patient's bed B. Providing warm chicken noodle soup C. Administering intravenous and oral fluids D. Turning on a fan or the air-conditioning system
Answer: D The nurse can incorporate nonpharmacologic interventions such as providing a fan or using the air conditioner to promote normal body temperature. Placing multiple blankets on the bed will retain the body heat and sweat and will not promote a normal body temperature. Fluids can help prevent dehydration. The hot and cold theory would suggest that the nurse provide cold foods such as fruits to a patient with a fever.
The nurse is evaluating teaching provided to the parents of a toddler about care of the child during a fever. Which parent statement indicates that teaching has been effective? A. "We should call the healthcare provider immediately if our child has a fever that lasts 16 hours." B. "We should call the healthcare provider within 24 hours if our child has a fever and difficulty breathing." C. "We should call the healthcare provider within 24 hours if our child has a fever and is drooling." D. "We should call the healthcare provider immediately if our child has a fever and purple spots on the skin."
Answer: D The parents should be instructed to call the healthcare provider immediately if the child has a fever and develops purple skin spots. The healthcare provider should be called immediately if the child with a fever is drooling or has difficulty breathing. The healthcare provider should be contacted if a child has a fever that lasts longer than 24 hours.
The nurse is assessing an 80-year-old patient admitted with delirium and hyperthermia. Which medical diagnosis should the nurse expect to find in the medical record as the most likely cause? A. Malignant tumor B. Autoimmune disorder C. Skin breakdown D. Urinary tract infection
Answer: D Thirty percent of fevers in older adults are attributed to an infection such as pneumonia or a urinary tract infection. A significant problem in treating older adults with an infection is that early symptoms may be atypical or nonexistent, and by the time the patient seeks medical attention, the infection may be overwhelming and difficult to treat. Behavioral changes and alterations in communication (e.g., delirium) are often the first observable signs that lead to suspicion of illness. Autoimmune disorders, wound infections, and malignancies can cause hyperthermia, but given the mental status change of delirium along with hyperthermia, an underlying infection is most likely.
A parent of an 8-year-old child with a viral infection says, "I've been giving my child acetaminophen. What else can I do to make my child more comfortable?" Which additional intervention should the nurse instruct the parent to provide? A. Draw a cool bath and have the child sit in the tub for a while. B. Bundle the child up with more warm clothes and blankets. C. Encourage the child to drink 1000 mL of fluid per day. D. Apply cool washcloths or ice bags to the axilla, groin, and forehead.
Answer: D When antipyretics do not provide relief, the nurse can instruct the parents to use alternative approaches to fever management. Therefore, the nurse would instruct the parents to apply cool washcloths or ice bags to the axilla, groin, and forehead. The nurse would instruct the parents to use a tepid, not cool, bath. Bundling the child up more would increase the body temperature. The nurse would instruct the parents to use less clothing. The nurse would instruct the parents to encourage the child to drink at least 2000 mL/day.
The nurse is preparing a presentation to parents about vehicle safety and heat-related injuries. Which important teaching point should be included? A. Store car keys in a visible place and within the children's reach in case of an emergency. B. Stay with a child in the car for up to 10 minutes with the windows cracked open. C. Leave a child alone in the car only if the outside temperature is below 80°F. D. Keep important articles in the backseat to ensure checking the area before leaving the vehicle.
Answer: D 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 caring for a client recovering from abdominal surgery. Which nursing action is most appropriate when monitoring a client for infection? A. Encouraging leg exercises while in bed B. Assisting out of bed and into a chair C. Turning and repositioning every 2 hours D. Assessing temperature every 4 hours
Answer: D Rationale: In order to monitor a client for infection, the best answer is assessing temperature at regular intervals. An increased temperature is an indicator of infection. While the other interventions are appropriate for this client, they do not allow the nurse to monitor for infection.
The nurse provided teaching to an older adult client about fevers. Which client statement indicates that the teaching was effective? A. "Cancer is the top source of fever in older adults." B. "I am less sensitive to environmental temperatures than when I was younger." C. "The rectal route is the best way to have my temperature taken." D. "I may not have a fever when I get sick or have an infection."
Answer: D 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.
Which type of body temperature changes in response to the environment? A. Core B. Metabolic C. Physiologic D. Surface
Answer: D Rationale: Surface temperature changes in response to the environment. Core temperature remains constant and stays within a specific range. Metabolic and physiologic are not types of body temperature.
