Deck 20: Thermoregulation

Question 1

A client with a body temperature of 104°F is entering the flush phase of the fever.Which actions by the nurse are appropriate when providing care? Select all that apply.

A) Restrict fluids.
B) Cover the client with a light sheet.
C) Monitor intake and output.
D) Cover the client with warm blankets.
E) Provide warmed intravenous fluids.

Answer 1

Cover the client with a light sheet.
Monitor intake and output.

Question 2

The nurse is caring for a client admitted with minor burns and elevated body temperature after being in a house fire.What should be included in this client's plan of care? Select all that apply.

A) Providing blankets
B) Keeping the room temperature warm
C) Restricting fluids
D) Encouraging fluids
E) Lowering room temperature

Answer 2

Encouraging fluids
Lowering room temperature

Question 3

The nurse assists with the delivery of a newborn on the labor and delivery unit.By drying the newborn immediately after birth,the nurse is protecting heat loss by which method?

A) Convection
B) Conduction
C) Evaporation
D) Radiation

Answer 3

Evaporation

Question 4

Victims of a boating accident were admitted to the hospital with the diagnosis of hypothermia.Which method of losing body temperature will the nurse plan for when providing care to these clients?

A) Vaporization
B) Insensible water loss
C) Convection
D) Insensible heat loss

Question 5

During an assessment,the nurse notes that a client who was a victim of an industrial accident has a mildly elevated body temperature.When discussing the client's increased temperature,which will the nurse attribute it to?

A) Infection
B) Diet
C) Exercise
D) Stress

Question 6

A client is admitted to the emergency department with a body temperature of 103°F.It is a hot and humid day,and the client works in a factory with no air conditioning.Which actions by the nurse are appropriate when providing care to this client? Select all that apply.

A) Use warm blankets.
B) Restrict fluids.
C) Apply cool washcloths to the face and neck.
D) Assess vital signs.
E) Remove or loosen clothing around the neck and chest.

Question 7

A nurse is caring for a client with a fever who is experiencing tachypnea.Which is true regarding this client's condition?

A) The decrease in prostaglandin production causes the respiratory rate to increase.
B) Although it sometimes occurs, an increased respiratory rate is not a common reaction to fever.
C) One degree of temperature elevation causes an increase in respiratory rate by two breaths per minute.
D) One degree of temperature elevation causes an increase in respiratory rate by four breaths per minute.

Question 8

A nurse working in an outpatient pediatric clinic is speaking to the mother of a school-age client who has a temperature of 101°F.Which statement should the nurse include when instructing the mother on treatment of the fever?

A) "Place the child in a cold bath."
B) "Administer aspirin by either chewable tablet or liquid suspension."
C) "It is not necessary to treat the fever at this point."
D) "If your child is shivering, it is okay to use several blankets to decrease discomfort."

Question 9

The nurse is caring for a client who is experiencing hyperthermia.Which intervention is appropriate for this client?

A) Applying warm blankets
B) Administering a prescribed antipyretic medication
C) Keeping limbs close to the body
D) Covering the scalp with a hat

Question 10

The mother of preschool-age client tells the nurse that the client has frequent fevers.Which response by the nurse is appropriate?

A) "Fevers are most frequently seen in children because of developing immunity."
B) "This is unusual because common diseases of childhood rarely result in fevers."
C) "Your child must be around people with illnesses."
D) "Your child's immunity is compromised."

Question 11

A client is started on antibiotic therapy for a respiratory infection.Which goal is appropriate for this client?

A) The client will have no evidence of sweating.
B) The client's mucus membranes will be dry.
C) The client's temperature will be within normal limits within 48 to 72 hours of the administration of the antibiotic.
D) The client's temperature will approach normal within 60 minutes of the administration of the antibiotic.

Question 12

A client is receiving care for an elevated body temperature.Which assessment findings indicate that care has been effective? Select all that apply.

A) Urine output of 20 ml/hour
B) Moist mucous membranes
C) Heart rate of 120 beats per minute
D) Good skin turgor
E) Blood pressure of 118/68 mmHg

Question 13

The nurse assesses a client's temperature to be 99.8°F.Which nursing diagnosis would be appropriate for the client at this time?

A) Hyperthermia
B) Anxiety
C) Risk for Imbalanced Body Temperature
D) Deficient Fluid Volume

Question 14

The nurse is providing care to a client who is experiencing an elevated body temperature.Which classification of medication does the nurse anticipate will be prescribed for this client?

A) Muscle relaxant
B) Antihypertensive
C) Sedative
D) Antipyretic

Question 15

A nurse educator is teaching a group of student nurses regarding heat and cold injuries.Which statement will the nurse include about thermoregulation?

A) "Core temperature varies widely depending on the outside environment."
B) "The body's surface temperature remains relatively constant."
C) "Chemical thermogenesis occurs with the increase of cortisol."
D) "All muscle activity, regardless of location, produces heat."

Question 16

An older adult client with a history of congestive heart failure (CHF)has a low-grade fever.Which action by the nurse is appropriate?

A) Provide warm blankets.
B) Restrict fluids.
C) Encourage getting out of bed to ambulate.
D) Notify the healthcare provider.

Question 17

A client is experiencing an elevated temperature.What should the nurse include in this client's plan of care? Select all that apply.

A) Administer warm intravenous fluids.
B) Apply warm blankets.
C) Provide dry clothing.
D) Increase oral fluid intake.
E) Administer antipyretic medication.

Question 18

An older adult client admitted with pneumonia has a normal body temperature.Which reason for this inconsistency in body temperature will the nurse plan for when providing care to this client?

A) The room is cold.
B) The client does not have pneumonia.
C) The temperature is not a valid indicator of the pathology of the illness.
D) The client is losing body heat.

Question 19

A client is admitted with the diagnosis of fever of unknown origin.Which diagnostic tests does the nurse anticipate for this client? Select all that apply.

A) CT scan of the abdomen
B) Chest x-ray
C) Urinalysis
D) Complete blood count
E) Bone scan

Question 20

The nurse needs to assess the body temperature of a client who has just smoked a cigarette and consumed hot coffee.Which temperature assessment method should the nurse use?

A) Axillary
B) Temporal artery
C) Tympanic
D) Rectal

Question 21

A client is admitted with a core body temperature of 93°F.Which action by the nurse is appropriate for this client?

A) Apply warm soaks to the extremities.
B) Use a hyperthermia blanket.
C) Provide warm fluids.
D) Use warm blankets.

Question 22

The nurse is planning to instruct a new mother on ways to prevent hypothermia in her newborn.What should this teaching include? Select all that apply.

A) Expect the baby to shiver.
B) Keep the newborn's head covered.
C) Cover the newborn with a light sheet during afternoon naps.
D) Notice changes in the baby's respirations and take the appropriate action.
E) Cover the newborn with minimal blankets when out of doors in temperatures in the 50s.

Question 23

A nurse is caring for a client with hypothermia and frostbite of the nose and fingers.Which action by the nurse is inappropriate for this client?

A) Massage frostbite areas to rewarm them and increase circulation.
B) Rapidly rewarm affected areas in circulating warm water.
C) Keep the client on bedrest with the affected parts elevated.
D) Debride blisters.

Question 24

A nurse working in labor and delivery is aware that newborns have several physiologic mechanisms that increase heat production to prevent hypothermia.What is true regarding newborn thermogenesis?

A) Shivering occurs when skin receptors perceive a drop in the environmental temperature and transmit sensations to stimulate the sympathetic nervous system.
B) Shivering thermogenesis uses the newborn's stores of brown fat to provide heat.
C) Brown fat produces heat generation, and heat transfer to the peripheral circulation.
D) The extra muscular activity by the infant in cold stress produces a large amount of body heat.

Question 25

A young adult client is admitted to the emergency department with symptoms of hypothermia.Which data collected during the health history supports this diagnosis? Select all that apply.

A) Wearing sandals
B) Consuming alcohol
C) Walking outdoors in 30°F weather
D) Wearing a hat
E) Standing outdoors during a snow storm without a coat

Question 26

A client is admitted to the emergency department complaining of the inability to feel the hands and feet after waiting for 2 hours for transportation in 20°F weather.Which action by the nurse is appropriate?

A) Warm the hands and feet in 104°F water for 20 to 30 minutes.
B) Provide an antipyretic.
C) Rub and massage the hands and feet.
D) Warm the hands and feet in tepid water for 2 hours.

Question 27

The nurse is educating a family who is planning an ice fishing trip on ways to prevent hypothermia.Which recommendation by the nurse is appropriate?

A) All family members should wear skid-proof footwear.
B) If someone becomes hypothermic, keep the clothing on, cover the person with damp blankets, and have the person drink a cool liquid.
C) All family members should light rain jackets.
D) If someone becomes hypothermic, remove any wet clothing, wrap the person in blankets, and have the person drink a warm liquid.

Question 28

A client has been receiving treatment for hypothermia.Which assessment finding indicates nursing interventions have been successful?

A) Current temperature of 95°F
B) Heart rate of 72 and regular
C) Continues to shiver
D) Blood pressure of 88/54 mmHg

Question 29

The nurse is providing care to a client who has a body temperature of 94°F,an irregular heart rate,and low blood pressure.Which is the priority intervention for this client?

A) Elevate the client's legs.
B) Provide a heating pad to the client's lower back.
C) Elevate the head of the bed.
D) Administer warmed intravenous fluids.

Question 30

A client has a body temperature of 95°F and exhibits slurred speech and poor coordination.Which is the priority nursing diagnosis for this client?

A) Disturbed Sensory Perception
B) Acute Confusion
C) Hypothermia
D) Imbalanced Body Temperature