Thermoregulation HCC
A recovery room nurse monitoring a client for adverse effects of cold cardioplegia assesses for:
Ventricular dysrhythmia
The nurse is assessing a client diagnosed with varicella. The nurse is aware that nonspecific manifestations may include:
fever
A client diagnosed with moderate hypothermia would likely experience the instillation of warmed fluids into the gastrointestinal tract and extracorporeal blood warming. This type of rewarming is referred to as:
Active core
Which intervention is an appropriate action by a nurse to take in attempting to decrease a client's temperature through conduction?
Apply cooling blanket
A client postoperative from an appendectomy reports feeling cold and has a temperature of 96.2°F (35.7°C). Which action should the nurse perform first?
Apply warm blankets to the client.
Which statement about temperature regulation and skin is accurate?
Arteriovenous anastomoses between an artery and a vein within the skin layer are important for temperature regulation.
Which statement concerning blood flow to the skin is true?
Arteriovenous anastomoses in the skin regulate temperature.
The preterm neonate has been in an incubator and is in medically stable condition and gaining weight. The nurse is preparing the neonate for transfer to an open cot. What will the nurse include in the care plan for this process?
Assess the neonate's temperature every 30 minutes during the transition. Decrease incubator temperature gradually until room temperature is reached. Dress the neonate in a sleeper and hat.
The surgical nurse is administering a unit of packed red blood cells to the postoperative client. Which of the following is the most common transfusion reaction?
Febrile reaction
For a client with Graves' disease, which nursing intervention promotes comfort?
Maintaining room temperature in the low-normal range
The nurse is monitoring a client who is 3 hours postpartum. On assessment, the nurse notes a temperature of 102.4°F (39.1°C). Which action should the LPN prioritize?
Notify the RN who will then notify the health care provider.
A group of students are reviewing information about acute rheumatic fever. The students demonstrate a need for additional review when they identify what as a major Jones criterion?
arthralgia
The nurse has admitted a small-for-gestational-age infant (SGA) to the observation nursery from the birth room. Which action would the nurse prioritize in the newborn's care plan?
closely monitor temperature
What medication should the nurse prepare to administer in the event the client has malignant hyperthermia?
dantrolene sodium
A nurse is preparing a presentation for a group of high school athletes about temperature regulation during activity such as practice. When describing the mechanisms of heat loss, which of the following would the nurse identify as primarily responsible when environmental temperatures are very high?
evaporation
A 33-year-old client is brought into the emergency room with a core temperature of 39°C (102.2°F). The client is red in the face, chest, and back due to significant cutaneous vasodilation. The client is likely in which stage of fever?
third
Surgery can lead to hypothermia. Which client is at greatest risk for hypothermia?
an older adult man with a fractured hip
A preterm infant is experiencing cold stress after birth. For which symptom should the nurse assess to best validate the problem?
apnea
The nurse examines a 26-week-old premature neonate. The skin temperature is lowered. What could be a consequence of the infant being cold?
apnea
Fever in infants and young children is not an uncommon event. Many trips to the pediatrician's office occur because of fever in children ages 1 day to 3 years. Which sign or symptom does not indicate fever in an infant?
avid feeding Avid feeding Hypoventilation Cyanosis Poor tissue oxygenation
A woman is 2 weeks postpartum when she calls the clinic and tells the nurse that she has a fever of 101°F (38.3°C). She reports abdominal pain and a "bad smell" to her lochia. The nurse recognizes that these symptoms are associated with which condition?
Endometritis
Which client who presented to a walk-in medical clinic is most likely to be diagnosed with rhinosinusitis rather than a common cold?
A man complaining of general fatigue, a headache, and facial pain with a temperature of 100.9°F (38.2°C)
The nurse is caring for an 85-year-old client hospitalized for dehydration. The nurse notices that the client is shivering and takes the client's temperature. The nurse notes an oral temperature of 97.8°F (36.6°C). The client also reports being "chilly." Which nursing action is most appropriate?
Offer the client an extra blanket.
A nurse is assessing a full-term neonate and discovers a heart rate of 100 beats/minute and an axillary temperature of 97.3°F (36.3°C). What action should the nurse take?
Place a cap on the neonate's head, and offer the neonate to the mother for skin-to-skin contact.
A client experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with
body temperature control
When an infection is bloodborne, the manifestations include which symptom?
chills
The nurse is preparing a teaching plan for new parents about why newborns experience heat loss. Which information about newborns would the nurse include?
limited voluntary muscle activity
A client experiencing alcohol withdrawal exhibits tremors, diaphoresis, and hyperactivity. Blood pressure is 190/87 mm Hg, and pulse is 92 bpm. Which medication should the nurse expect to administer?
lorazepam
A client with schizophrenia started risperidone 2 weeks ago. Today, the client reports feeling flu-like symptoms. The nurse's assessment reveals the following: temperature 104.4° F (40.2° C), respirations 24 breaths/minute, blood pressure 130/102 mm Hg, pulse rate 120 beats/minute. The nurse also notes muscle stiffness and pain, excessive sweating and salivation, and changes in mental status. The nurse suspects the client is experiencing:
malignant hyperthermia
A client with an elevated temperature is beginning to sweat. The nurse interprets this as being an example of:
negative feedback mechanism
A client has a fever that was induced by damage to the hypothalamus due to intercranial bleeding. The nurse plans care for which type of fever?
neurogenic
A two-day postoperative client's temperature was 98.5°F (36.9°C) at 3:00 pm. At 6:00 pm, the unlicensed assistant (UAP) notifies the nurse that the client's temperature is 102°F (38.9°C). Which action should the nurse take?
notify the physician
A client is said to be in the chill stage of the fever process when the nurse:
observes piloerection on the skin.
A client with HIV has a low-grade fever, a rash, swollen lymph nodes, pharyngitis, and states, "I feel like I've been having the flu for the past 5 days." No reports of diarrhea, nausea, or weight loss. Which phase of HIV infection is the client most likely exhibiting?
primary infection
A client complains of general malaise and fatigue and has a mild fever. The nurse would evaluate this stage of disease as the:
prodromal stage
A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn?
radiation, convection, and conduction
A hospital client who is being treated for acute kidney injury has developed an oral temperature of 39.1°C (102.4°F) despite the absence of other signs and symptoms of infection. When attempting to determine the etiology of the client's fever, the nurse should:
review the client's recent medication history.
A child is diagnosed with group A streptococcal pharyngitis. The nurse would teach the parents to be alert for signs and symptoms of:
scarlet fever
A 54-year-old man presents with a temperature of 38.8°C (101.8°F), a racing heart, fatigue, and an upset stomach after spending an afternoon building a deck on a very hot, humid day. The physician assessing the man is performing a differential diagnosis as part of her assessment. Which finding would suggest fever rather than hyperthermia as a cause of the elevation in the man's temperature?
shivering
Which clinical manifestation is often the earliest sign of malignant hyperthermia?
tachycardia (heart rate >150 beats per minute)
An episiotomy or a cesarean incision requires assessment. Which assessment criterion for skin integrity is not initially noted?
temperature
A nurse is teaching new parents about keeping follow-up appointments and calling their health care provider if they notice signs of illness in their newborn. The nurse determines that the teaching was successful when the parents identify which signs as needing to be reported?
temperature of 38.3° C (101° F) or higher refuse feeding abdominal distention general fussiness approximately eight wet diapers a day ?????
The nurse is teaching nursing students about the risks that late preterm infants may experience. The nurse feels confident learning has taken place when the students make which statement?
"A late preterm newborn may have more clinical problems compared with full-term newborns."
The nurse evaluates which core body temperature as outside the normal range?
36.2°C (97.1°F) 37.4°C (99.3°F) 96.8°F (36°C) 99.6°F (37.5°C) ?????
A child asks about the purpose (function) of "white" fat. Which responses by the nurse are best? Select all that apply.
It makes everyone unique by proportioning fat in various body parts. It stores energy for the body to use. It regulates temperature through insulation. It releases protein to generate heat in the skeletal muscles. It cushions vital organs of the body. ????
A nurse is caring for a child with Kawasaki disease. Which assessment finding would the nurse expect to see?
Peeling hands and feet; fever
Which statement is false regarding bathing the newborn?
The bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth.
The nurse is recording vital signs in the client diagnosed with complications of anorexia nervosa. Which findings are consistent with the condition?
hyperthermia orthostatic hypotension weak pulse hypothermia hypertension ??????
A 7-year-old child with an earache comes to the clinic. The child's parent reports that 1 day ago the child had a fever and headache and did not want to play. When the nurse asks where it hurts, the child points to the jawline in front of the earlobe. What does the nurse expect the diagnosis will be for this child?
mumps
Which finding is indicative of hypothermia of the preterm neonate?
nasal flaring
An older adult client dressed only in a hospital gown requests a warm blanket for "a draft in the room." Which mechanisms of heat loss are the likely cause of the client's request?
radiation and convection
The route considered the most accurate to measure a core body temperature is:
rectal
Which site results in measuring a client's core body temperature?
rectal
The nurse instructor is reviewing the integumentary system during a presentation to a group of student nurses. Which statement made by the instructor is the most accurate regarding the integumentary system?
"The largest organ of the body helps regulate body temperature."
The nurse has completed an education session with parents of children diagnosed with food allergies. Which statement by a parent would indicate a need for additional education?
"If we need to use the EpiPen® we will need to notify her physician's office the next business day."
A client is admitted with frostbite. What will the nurse tell the client about the changes that have occurred due to cold exposure?
Cold increases blood viscosity and thrombosis.
A patient develops malignant hyperthermia after receiving a NMJ blocker. Which would the nurse expect to be given?
Dantrolene
A hiker presents to the emergency department with reports of flu-like symptoms—thirst, nausea, and inability to urinate. Upon assessment, it is determined that the client has a rectal temperature of 102.2°F (39°C) and is tachycardic. These symptoms support a diagnosis of:
Heat exhaustion
A febrile, 3-week-old infant is currently undergoing a diagnostic workup to determine the cause of the fever. Which statement conveys the rationale for this careful examination?
Infants are susceptible to serious infections, because of their decreased immune function.
The nurse is explaining the ultrasound procedure to a pregnant client and mentions part of the purpose is to evaluate the amniotic fluid. When questioned by the client how the amniotic fluid helps the fetus, which functions should the nurse point out?
Provides physical protection Produces necessary hormones Provides unrestricted movement Helps regulate temperature
A client with pneumonia is admitted with these vital signs: temperature 99.7ºF (37.6°F), pulse 80 beats/min, respirations 18/minute, and BP 120/80 mm Hg. Which set of vital signs does the nurse anticipate when the client begins to shiver and requests another blanket several hours later?
T 100.9ºF (38.3°C), P 90/min, R 20/min, BP 126/80 mm Hg
A nurse caring for an older adult who has been diagnosed with a urinary tract infection checks the client's temperature on admission and finds that it is 96.6°F (35.9°C). Which statement describes how the nurse should interpret the finding?
The client may be exhibiting a blunted or absent febrile response.
A pregnant client is undergoing a fetal biophysical profile. Which parameter of the profile helps measure long-term adequacy of the placental function?
amniotic fluid volume
The nurse is applying a cool compress to the forehead of a client with an elevated temperature. This is an example of what type of heat loss?
conduction
A client develops malignant hyperthermia. What client symptom would the nurse most likely observe as the first indicator of the disorder?
heart rate over 150 beats per minute
Which finding might be seen in a neonate suspected of having an infection?
decreased temperature
What is a consequence of hypothermia in a newborn?
holds breath 25 seconds
A preterm infant has an umbilical vessel catheter inserted so that blood can be drawn readily. Which would be most important to implement during this procedure?
Ensure that the infant is kept warm.
Which of the following areas of the brain are responsible for temperature regulation?
hypothalamus
A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to:
rest in an air-conditioned room.
Which temperature readings indicate to the nurse that the clients have fever?
35-year-old with pulmonary artery reading of 37.9ºC (100.2ºF) 19-year-old with oral reading of 38.4ºC (101.1ºF) 3-day-old with rectal reading of 38ºC (100.4ºF)
The nurse is caring for a client with an infection and fever. The client reports feeling chilled and having "goose bumps." The nurse will anticipate what change in the client's assessment findings as a result of this physiologic reaction?
An increase in body temperature
The perioperative nurse is caring for a client who is undergoing abdominal surgery with the inclusion of succinylcholine in the client's anesthesia. The anesthesiologist tells the team that the client is exhibiting signs and symptoms suggestive of malignant hyperthermia. What is the nurse's best action? You Selected:
Anticipate IV administration of dantrolene
The nurse is caring for a child who has suffered a febrile seizure. While speaking with the child's parents, which statement by a parent indicates a need for further education?
"I hate to think that I will need to be worried about my child having seizures for the rest of his life." "When he gets his next set of immunizations, I need to make sure I give him some ibuprofen so he doesn't spike a fever." "I need to set an alarm to wake up and check his temperature during the night when he is sick." "The next time he has a fever, I need to make sure I read the dosage on the acetaminophen bottle carefully."
Parents tell the nurse they have been told to keep their newborn away from windows. They do not understand why this is necessary. Which rationale will the nurse provide to the parents?
"Newborns cannot shiver to produce heat and need to be kept away from sources of heat loss."
The nurse is explaining to a group of nursing students the proper technique for obtaining an accurate temperature on a child. The instructor determines the session is successful when the students correctly choose which factor as related to taking a temperature?
"Rectal temperatures should not be taken on a child with diarrhea."
A nurse is teaching a prenatal class and is asked the purpose of amniotic fluid. Which statements are correct?
Amniotic fluid allows the fetal umbilical cord to be relatively free from compression. Sufficient amounts of amniotic fluid help the fetus maintain a constant body temperature. Sufficient amounts of amniotic fluid cushion the fetus from trauma. Amniotic fluid promotes fetal movement enhancing musculoskeletal development. and...??? The amount of amniotic fluid does not fluctuate throughout pregnancy.
A nurse is required to obtain the temperature of a healthy newborn who was placed in an open crib. Which is the most appropriate method for measuring a newborn's temperature?
Place electronic temperature probe in the midaxillary area.
An emergency nurse working in a military hospital admits a new military recruit who collapsed during a heavy training exercise in the desert. The skin is moist, the pulse is 120 beats/minute, and the respirations are 28/minute. What interventions will the nurse implement?
Remove client's heavy clothing. Keep the environment cool. Provide fluid resuscitation.
An 11-year-old child was recently diagnosed with chickenpox. His parents gave him aspirin for a fever and the child is now hospitalized. Which nursing interventions are appropriate for this child?
Request order for an antiemetic. Assess intake and output every shift. Request order for anticonvulsant.
Antipyretic drugs, such as aspirin, ibuprofen, and acetaminophen, are often used to alleviate the discomforts of fever and protect vulnerable organs, such as the brain, from extreme elevations in body temperature. The use of aspirin is limited in children, however, because it can sometimes cause which disease?
Reye Syndrome
A nurse conducting a community education program on hyperthermia determines that the participants understand the information when they identify that the heat index is which of the following?
Temperature sensed when temperature and humidity are combined
A nurse is providing care for a 44-year-old male client who is admitted with a diagnosis of fever of unknown origin (FUO). Which characteristic of the client's history is most likely to have a bearing on his current diagnosis?
The client is HIV-positive and homeless. The client is malnourished, hypomagnesemic, and hypocalcemic. The client is receiving intravenous normal saline with 20 mEq KCl. The client is cachexic and black. The client is HIV-positive and homeless.
The client has arrived in the short stay unit for an infusion of tositumomab with 131 tositumomab. Before beginning the infusion, the nurse assesses the client's vital signs and finds the client has a temperature of 101.5°F (38.6°C). What is the nurse's best action?
Treat the fever as ordered before beginning the therapy.
The nurse is assisting with the preparation of a teaching plan for a client who is to receive methimazole (Tapazole). Which of the following would be most appropriate to include in this plan?
Urging the client to report any fever or sore throat.
The parents of a 1-day-old newborn are concerned the newborn is cold. Which action should the nurse prioritize to best prevent heat loss?
Warm all surfaces and objects that come in contact with the newborn
The nurse is assessing clients for basal metabolic rate (BMR). Which client would the nurse suspect would have an increased BMR?
a client who has a fever
The nurse is caring for a client with peripheral vascular disease (PVD). Which action would the nurse do to ensure an accurate assessment?
keep the client warm
A client with a history of malignant hyperthermia is scheduled for surgery. Which agent would the nurse most likely expect to administer?
dantrolene
The nurse is assisting in the care of a client during surgery. The nurse will be prepared to administer which drug if the client develops malignant hyperthermia?
dantrolene sodium
A client with an upper respiratory infection has been prescribed macrolides. Which changes during an ongoing assessment would lead the nurse to notify the health care provider?
decrease in blood pressure increase in respiratory rate sudden increase in temperature regular urine output pulse rate within usual parameters ????
The nurse provides care to a client who is diagnosed with schizophrenia. A family member asks the nurse, "I don't know how she tolerates wearing that winter coat in the middle of the summer!" Which structure of the limbic system should the nurse base the response?
hypothalamus
A client was stranded when the automobile broke down while traveling in the mountains. The client had to walk 15 miles to the nearest gas station, and the outside temperature was 20°F (-7°C). The nurse will assess the client for complications related to which physiologic response to cold?
increased blood viscosity and vasoconstriction
A nurse notes that a client with a fever has begun to shiver. The nurse should assess for which finding?
increased temperature
The temperature is 102°F (39°C) during a heat wave. The nurse can expect admissions to the emergency room to present with:
increased temperature.
A nurse is teaching the parents of a child with sickle cell disease. The nurse determines that the teaching was successful when the parents identify which conditions as factors that predispose the child to a sickle cell crisis?
infection cold air temperature