Thermoregulation Adaptive Quiz
While conducting an assessment, the nurse finds that the client shivers uncontrollably and experiences memory loss, depression, and poor judgment. Which might the client's body temperature be? A) 84.3F B) 91.4F C) 98.6F D) 100.4
B When skin temperature drops below 95F, the client may exhibit uncontrolled shiver, loss of memory, depression, and poor judgment as a result of hypothermia. A body temperature lower than 86F represents severe hypothermia. In this condition, the client will demonstrate a lack of response to stimuli and extremely slow respirations and pulse. A body temperature in the range of 98.6F - 100.4F is normal.
The nurse assesses for which client symptoms that indicate hyperthermia? A) Vasodilation B) Dry and flushed skin C) Pale and cyanotic skin D) Decreased capillary refill E) Decreased urinary output
A,B,E During hyperthermia, vasodilation occurs that causes the flushed appearance of the skin; as a result, the skin may be warm to the touch. Hyperthermia causes loss of water from the body and results in dry skin and mucous membranes, decreased urinary output; increased not decreased capillary refill, and other signs of dehydration and electrolyte imbalance.
Which structure is likely damaged in a client with a head injury who temperature rapidly increased to 102.2F? A) Thalamus B) Hypothalamus C) Temporal lobe D) Globus pallidus
B Hypothalamus is known as the body's thermostat.
Which changes that occur with aging increase the risk for hypothermia in older adults? Select all that apply. A) Increase metabolic rate B) Increased shivering response C) Decreased amount of body fat D) Diminished energy reserves E) Chronic medical conditions
C,D,E
Which antipyretic medication may cause Reye syndrome in children? A) Aspirin B) Naproxen C) Ibuprofen D) Dantrolene
A Aspirin increases the risk of swelling in the brain and liver, which are the main symptoms of Reye syndrome in children.
Which initial intervention would the nurse perform for the child who presents in the emergency department with sustained frostbite of toes? A) Rewarm the toes by placing the feet in warm water B) Gently rub the toes with snow C) Place the feet in iced water to minimize the temperature difference D) Wrap the feet in an ice pack until definitive medical help is available
A Rewarming is accomplished by immersing the body part in well-agitated water at 100F to 108F. Rewarming minimizes the tissue damage.
The nurse concludes that a client with a body temperature of 98.6F is experiencing which condition? A) Hypothermia B) Hyperpyrexia C) Hyperthermia D) Normothermia
D A body temperature of 98.6F is normal.
Which passive warming measures would the nurse use to promote the warmth and comfort of a client experiencing hypothermia? Select all that apply. A) Warmed socks B) Radiant warmer C) Warm forced air D) Reflective blanket E) Humidified oxygen
A,D A reflective blanket and warm socks are passive warming measures. The use of a radiant warmer, forced warm air, and humidified oxygen are active warming measure.
Which nursing intervention would the nurse provide to prevent heat loss in the neonate immediately after birth? A) Bottle feeding immediately after birth B) Dressing the newborn in a shirt and gown immediately C) Bathing the newborn in warm water as soon as possible D) Putting the naked newborn on the mother's bare chest
D Skin-to-skin contact between mother and infant is most effective in maintaining the infant's body temperature; heat is transferred by way or conduction. A radiant warmer is effective if the mother or newborn is unable to engage in immediate skin-to-skin contact. Bathing the newborn's should be delayed until the newborn's body temperature has been stabilized.
Arrange the sequence of events occurring during a fever in chronological order. 1. Body temperature is increased. 2. Immune system response is triggered. 3. Pyrogens are destroyed 4. The set point of the hypothalamus is raised. 5. Heat loss responses are initiated.
2, 4, 1, 3, 5 A fever results from an alteration in the hypothalamic set point. Pyrogens act as antigens that trigger the immune system response. The hypothalamus reacts by raising the set point, thereby increasing he body temperature. Once the pyrogens are removed, the third phase of febrile episode occurs. Heat loss responses are initiated when the hypothalamus set point drops.
Which action by the emergency department nurse is the priority for a client with heat stroke? A) Assess the airway and breathing B) Administer diazepam to prevent shivering C) Apply ice packs to the axilla, groin, head, and neck D) Ask the client to state his or her name and date of birth
A Assessment and establishment of ABCs are the priority in the heat stroke client because absence of ABCs is an immediate threat to life.
A client with hypothermia is brought to the emergency department. Which treatment would the nurse anticipate? A) Core warming with warm fluids B) Ambulation to increase metabolism C) Frequent oral temperature assessments D) Gastric tube feedings to increase fluid volume
A Core warming with heated oxygen and administration of warmed oral or IV fluids is the preferred method of treatment. The client will be too weak to ambulate. Oral temperatures are not the most accurate assessment of core temperature because of environmental influences. Warmed oral feedings are advised; gastric tube feedings are unnecessary.
When a client is using a hypothermia blanket to reduce fever, which finding indicates a need for a change in treatment? A) Shivering B) Vomiting C) Dehydration D) Hypotension
A Shivering should be prevented because peripheral vasoconstriction increases temperature, circulatory rate, and oxygen consumption. Hypothermia therapy does no cause vomiting, and vomiting is not an indication of a need to modify hypothermia. Dehydration is not a response to hypothermia therapy, although fever can cause dehydration if oral or parenteral fluid intake is inadequate to maintain fluid balance. Hypotension is not a response to hypothermia therapy, although hypotension can occur with dehydration if oral or parenteral fluid intake is inadequate to maintain fluid balance.
Which heat loss mechanism would the nurse minimize by swaddling a newborn infant with a blanket? A) Radiation B) Conduction C) Active transport D) Fluid evaporation
A Swaddling the baby with a blanket prevents heat loss through radiation (from the warm baby to the atmosphere).
Which nursing interventions help prevent heat loss in newborns? Select all that apply. A) The nurse keeps the newborn covered in warm blankets. B) The nurse keeps the newborn under the radiant heater. C) The nurse places the newborn on the mother's abdomen. D) The nurse measures the newborn's temperature regularly. E) The nurse encourages the mother to feed the newborn well to maintain the fluid balance.
A,B,C Newborns have impaired thermoregulation due to immaturity of the body systems. The nurse performs interventions to prevent heat loss in the newborn. Covering the newborn with warm blankets helps prevent heat loss. The nurse keeps the newborn under the radiant warmer to help maintain the body temperature. Placing the newborn on the mother's abdomen helps promote warmth through skin-to-skin contact. Regular measurement of temperature may help in assessing any significant change; however, it may not help prevent heat loss. Ensuring that the newborn is fed well does not help prevent heat loss.
Which signs and symptoms are observed in the human body with a decrease in body temperature? Select all that apply. A) Shivering B) Profuse sweating C) Flushed appearance D) Dilation of blood vessels E) Contraction of blood vessels
A,E A client who has decreased body temperature may experience shivering due to contraction of the blood vessels in the body. The client who has decreased body temperature may not experience profuse sweating, flushed appearance, and dilated blood vessels. These signs and symptoms appear with an increase in body temperature.
When a client arrives in the emergency department after prolonged exposure to cold weather, which clinical manifestations will the nurse expect to find? Select all that apply. A) Stupor B) Erythema C) Increased anxiety D) Rapid respirations E) Paresthesia in affected body parts
A,E Stupor may occur with hypothermia because of slowed cerebral metabolic processes. Peripheral vasoconstriction and the effect of cold on the peripheral nervous system result in paresthesia in the affected body parts. Pallor, not erythema, is present as a result of peripheral vasoconstriction. Drowsiness occurs; the client is unable to focus on anxiety-producing aspects of the situation. Respirations are decreased.
Which clinical parameter will be most important for the nurse to assess when administering warmed IV fluids to a client with hypothermia? A) Hematocrit B) Cardiac rhythm C) Intake and output D) Blood urea nitrogen
B Dysrhythmias can occur during rewarming and may need treatment. Ongoing cardiac monitoring is essential. Hematocrit may increase with hypothermia and would be expected to improve with administration of warm fluids, but changes in hematocrit during rewarming are expected. I/O would be monitored during IV infusion but are not as important to monitor as cardiac rhythm. Renal failure may occur as a complication of hypothermia and blood urea nitrogen would be monitored, but is not as important to monitor as cardiac rhythm.
Which condition would the nurse avoid applying external rewarming devices due to a contraindication? A) Frostnip B) Frostbite C) Severe hypothermia D) Moderate hypothermia
C The nurse would avoid active external rewarming for the client with heating devices in cases of severe hypothermia. Extreme heating is contraindicated in this kind of client because of rapid vasodilation. Frostnip is a type of superficial cold injury that can be treated with warmth without causing any tissue damage. In case of frostbite, the nurse would not use dry heat or massage the frostbitten area of the client's body. Moderate hypothermia can be cured by both active external and core rewarming methods.
A child is sent to the school nurse on a snowy, below freezing day because he arrived without a coat, wearing shorts, and T-shirt, and sandals. Which is the first nursing intervention? A) Provide warm liquid to drink B) Check the child for frostbite C) Call Child Protective Services D) Ask the child who helped him dress
B The child must first be assessed for injuries caused by exposure and treated if necessary. A warm liquid may be offered after the child's physical status is assessed and it is determined that fluids may be ingested. Child Protective Services may be called after further assessment and the determination that neglect may be involved. Questions about the child's family dynamics may be asked after the status of the child is evaluated.
Which action would the nurse take to prevent the loss of heat through convection in a newborn? A) Dry the infant immediately after birth B) Keep the infant's crib away from the window C) Cover the scale before weighing the infant D) Wrap the infant in blankets, and place a cap on the head
B The crib should be kept away from the window to prevent heat loss through convection. The scale should be covered before weighing the infant to prevent heat loss through conduction. The infant should be thoroughly dried after birth and wrapped in blankets with a cap placed on the head to prevent heat loss through evaporation.
When a client in the emergency department has a blood pressure of 90/60, weak quality rapid pulse of 108 beats/min, and reports working outside for several hours on a hot day, which prescribed action would the nurse take first? A) Complete a head-to-toe assessment B) Start infusion of normal saline 500ml C) Ask the client about current medications D) Obtain blood samples for laboratory testing
B The low blood pressure, tachycardia, and report of being outside for several hours on a hot day suggest hypovolemia, indicating a need for immediate fluid replacement. The head-to-toe assessment is important, but can be completed after the IV fluids are started. Asking about the client's usual medications is necessary, but this information would not affect the decision for fluid infusion in this hypovolemic client. The client will need to have blood drawn to check electrolytes and renal function, but the infusion of fluids to prevent complications such as acute kidney injury is the important priority.
Which interventions are appropriate for the client brought to the hospital with heat exhaustion? Select all that apply. A) Salt tablets B) 0.9% normal saline IV C) Placing a moist sheet over the client D) Initial fluid bolus to correct hypotension E) Placing in a cold area and removing constrictive clothing
B,C,D,E For a client with heat exhaustion, it is appropriate to start an IV of normal saline, especially if oral replenishment is not tolerated. Placing a moist sheet over the client will decrease core temperature through evaporative heat loss. It is also reasonable to provide an initial fluid bolus to correct hypotension and to place the client in a cold area and remove constrictive clothing. Salt tablets are not recommended, because they carry the potential to cause gastric irritation and hypernatremia.
The nurse expects a client with an elevated temperature to exhibit which indicators of pyrexia? Select all that apply. A) Dyspnea B) Flushed face C) Precordial pain D) Increased pulse rate E) Increased blood pressure
B,D Increased body heat dilates blood vessels, causing a flushed face. The pulse rate increases to meet increased tissue demands for oxygen in the febrile state. Fever may not cause difficult breathing. Pain is not related to fever. Blood pressure is not expected to increase with fever.
Which nursing action would the nurse take for an infant after reporting a fever of 103.0F to the practitioner? A) Covering the infant with a bath blanket B) Sponging the infant with tepid alcohol C) Removing excess clothing from the infant D) Reassessing the infant's temperature in several hours
C After the initial safety measures and notification of the practitioner have been addressed, excess clothing, which prevents heat loss, should be removed. Covering the infant will increase the temperature because heat loss will be reduced. Alcohol should never be used for infants or children; it causes severe chilling, which can lead to increased metabolic activity and a higher temperature. This high fever requires more frequent readings, usually at least every hour.
An unresponsive adult client is admitted to the emergency department on a hot, humid day, with hot, dry skin, a respiratory rate of 36 breaths/min, and a heart rate of 128 beats/min. Which action will the nurse take first? A) Offer cool fluids. B) Suction the airway. C) Remove the clothing. D) Prepare for intubation.
C The client is likely experiencing hyperthermia. Clothing retains body heat and must be removed before other cooling methods are employed to reduce body temperature. Offering fluids is contraindicated because the client is unresponsive. There are no data to indicate an immediate need for suctioning, although the nurse will monitor the client for inability to clear the airway. Intubation may become necessary, but it is not the initial action.
Which client body temperatures are indicative of moderate hypothermia? Select all that apply. A) 80F B) 84F C) 88F D) 92F E) 96F
C,D Mild hypothermia: 93.2F - 96.8F Moderate hypothermia: 86F - 93.2F Severe hypothermia: <86F
A primary health care provider prescribes the application of a warm soak to an IV site that has infiltrated. The application of local heat transferring temperature to the body is which principle? A) Radiation B) Insulation C) Convection D) Conduction
D Conduction is the conveyance of energy such as heat, cold, or sound by direct contact. Direct contact is not necessary to convey heat by radiation. Insulation refers to the retention of heat, not its transfer. Convection is the transfer of heat by air circulation (e.g. by fans or open windows).
A child's blood test after receiving a general anesthetic indicates increased intracellular calcium levels. Which medication would the nurse anticipate administering to this client? A) Aspirin B) Naproxen C) Ibuprofen D) Dantrolene
D General anesthetic sometimes causes malignant hyperthermia in clients. Characteristics of malignant hyperthermia are an increased levels of intracellular calcium in the body. Dantrolene sodium reduces the muscle tone and metabolism to decrease the calcium levels in the body and antagonizes the effects of malignant hyperthermia. Do not administer aspirin to a children because it increases the risk of Reye syndrome. Naproxen and ibuprofen may not reduce calcium levels in the body, and thus are unable to reverse the effects of malignant hyperthermia.
While assessing a newborn, the nurse notes that the infant's skin is mottled. Which would the nurse's primary intervention be? A) Administer oxygen B) Offer an oral feeding C) Notify the practitioner D) Warm the environment
D Mottling results from hypothermia; the newborn should be wrapped, placed under a radiant warmer, or given the to the mother for skin-to-skin contact. Mottling is a phenomenon that usually indicates a decreasing temperature; the newborn requires warming, not oxygenation or medical attention. Feeding will not increase the newborn's temperature.
While assessing a neonate's temperature, the nurse observes a drop in the body temperature. Which reason explains this temperature drop? A) Increased basal metabolic rate B) Decreased involuntary shivering C) Increased voluntary movements D) Decreased non-shivering thermogenesis
D Neonates are susceptible to heat loss or cold stress. Non-shivering thermogenesis is a natural mechanism of heat production that occurs to minimize heat loss in a neonate. The mechanism's failure may lead to a drop in body temperature.
Which is the first sign that would assist the nurse in suspecting malignant hyperthermia in a client? A) Abnormal rapid heart rate B) Abnormal rapid breathing C) Increased body temperature D) Increased expired carbon dioxide
D The first sign of malignant hyperthermia is increased expired carbon dioxide, caused by an abnormal and continuous contraction of skeletal muscles. Due to metabolic changes in the skeletal muscles, there may be abnormal rapid breathing (tachypnea) and abnormal rapid heart rate (tachycardia), but it is not considered the first sign of malignant hyperthermia. Increased body temperature is often late to appear during malignant hyperthermia.
Which condition would the nurse expect to be responsible for a client's increasing incoherence and periods of stupor after wandering outside in the cold without a coat? A) Frostnip B) Mild hypothermia C) Severe hypothermia D Moderate hypothermia
D The nurse would expect moderate hypothermia with increased incoherence and stupor. Frostnip is a type of superficial cold injury that may produce pain, numbness, and pallor but is easily relieved by applying warmth. This condition does not cause tissue damage. Mild hypothermia is characterized by shivering and decreased muscle coordination. Symptoms of severe hypothermia are bradycardia, severe hypotension, and decreased coordination.