Deck 20: Thermoregulation

Question 1

A nursing student is discussing thermoregulation with fellow students. Which statement about thermoregulation does the student recognize as being true?

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."

Answer 1

"All muscle activity, regardless of location, produces heat."

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 to address the elevated body temperature? 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

A client is admitted with the diagnosis of fever of unknown origin. Which diagnostic test does the nurse anticipate for this client?

A)CT scan of the abdomen
B)Bone scan
C)Glucose tolerance test
D)Complete blood count

Answer 3

Complete blood count

Question 4

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 5

The nurse assists with the examination of a newborn in the newborn nursery. Prior to placing the child on the exam table, she spreads a cotton pad over the surface. By doing so, the nurse is protecting against heat loss by which method?

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

Question 6

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

A)Anticholinergic
B)Antihypertensive
C)Antiemetic
D)Antipyretic

Question 7

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 mucous 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 8

Which hormone is responsible for epinephrine release and thus chemical thermogenesis?

A)Norepinephrine
B)Thyroxine
C)Progesterone
D)Aldosterone

Question 9

The nurse is caring for a client who presents to the emergency department after a boating accident in which the client nearly drowned. The nurse understands that which type of heat loss resulted in a diagnosis of hypothermia?

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

Question 10

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 11

In the past, a college campus in a cold climate has had multiple students require treatment for mild hypothermia during the winter months. Which method would be most effective for the campus nurse to use to promote healthy thermoregulation on this campus?

A)Show a video about the harmful effects of hypothermia due to exposure.
B)Put up posters encouraging students to wear hats and mittens.
C)Sell inexpensive pocket handwarmers in the campus bookstore.
D)Send emails telling students that alcohol consumption prevents hypothermia.

Question 12

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 13

A hospitalized client with a body temperature of 104°F is entering the flush phase of the fever. Which action by the nurse is appropriate when providing care?

A)Restricting fluids.
B)Monitoring intake and output.
C)Covering the client with warm blankets.
D)Providing warmed intravenous fluids.

Question 14

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 15

The nurse is caring for an older adult client who was admitted with pneumonia. The client's vital signs are: P 84, R 22, BP 118/74, T (oral)98.3°F. The client asks the nurse to explain how she can have an infection without having a fever. How should the nurse respond?

A)The cool temperature of the hospital room helps prevent fevers.
B)The client was likely misdiagnosed and does not have an infection.
C)The body's ability to respond to changes in temperature declines with age.
D)The loss of body heat associated with pneumonia reduces the risk of fever.

Question 16

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 with a normal appearance and few signs of discomfort. 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 17

A client presents in the emergency department with a core body temperature of 88.8°F. The nurse understands that this temperature indicates this patient is

A)normothermic.
B)mildly hyperthermic.
C)febrile.
D)moderately hypothermic.

Question 18

A client is experiencing an elevated temperature due to a viral illness. What should the nurse anticipate being included in this client's plan of care? Select all that apply.

A)Administer warm intravenous fluids.
B)Apply warm blankets.
C)Keep limbs close to body.
D)Increase fluid intake.
E)Administer antipyretic medication.

Question 19

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 20

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 outside in the sun. 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 21

A client is admitted to the emergency department complaining of the inability to feel the hands and feet after exposure to 20°F temperatures for more than 2 hours. 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 22

What is the primary means of assessing the severity of hyperthermia?

A)Core temperature measurement
B)Skin temperature measurement
C)Clinical presentation of the client
D)Client history related to current condition

Question 23

A nurse working in a gerontologist's office is reviewing the files of patients who have appointments today. Of these patients, which one should the nurse identify as having the lowest risk for developing hypothermia?

A)An 80-year-old client with hypothyroidism and a lengthy medication regimen
B)A 69-year-old client with type 2 diabetes mellitus and peripheral neuropathy
C)A 75-year-old client with decreased subcutaneous fat and several dietary restrictions
D)A 78-year-old client who regularly walks and does strength training with small hand weights

Question 24

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 hypothermia blanket.
C)Provide warm fluids.
D)Use warm blankets.

Question 25

A client who has experienced head trauma may undergo induced hypothermia for what purpose?

A)To reduce metabolic rate and oxygen need
B)To reduce the risk of internal bleeding
C)To reduce the risk of a brain hemorrhage
D)To reduce glycogen consumption

Question 26

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 27

A 31-year-old pregnant client in her second trimester of pregnancy presents in the doctor's office with a fever of 102°F. The client is extremely upset and concerned that her elevated temperature may harm her unborn child. Which statement should the nurse include when explaining the client's risk?

A)"Maternal fever is only problematic when it reaches 103° or higher, but temperatures below this level are generally not a concern."
B)"Maternal fever is not associated with birth defects; rather, the medication taken to reduce the fever may cause problems."
C)"Maternal fever is a concern during pregnancy, but the risk to the child is greatest during the first trimester."
D)"Maternal fever is not associated with birth defects, but other types of hyperthermic exposure are associated with them."

Question 28

When flushing occurs in a client with a fever, what underlying mechanism to restore normal temperature is occurring?

A)Increased metabolism
B)Vasodilation
C)Insensible water loss
D)Increased thyroxine output

Question 29

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

A)The client was wearing a coat when the EMTs found him.
B)The client had a blood alcohol level of 0.12.
C)The client forgot to eat lunch.
D)The client was wearing a winter hat at the time of admission.

Question 30

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, sponge tepid water onto any exposed skin.
C)All family members should wear 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 31

A client has been receiving treatment for hypothermia. Which evaluation 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 32

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 33

A nurse is working in the labor and delivery unit. What statement does the nurse understand 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 34

Why are interval vital sign measurements an important prevention measure for hyperthermia in the clinical setting?

A)They are useful for monitoring for infection and inflammation.
B)They are important for establishing a client's baseline temperature.
C)They are essential to determining the cause of a fever of unknown origin.
D)They are helpful for monitoring a client's reaction to antipyretics.

Question 35

The nurse is caring for a 73-year-old client. When assessing temperature, which finding would the nurse report immediately to the provider as a potential sign of sepsis?

A)The client's temperature is below his baseline temperature.
B)The client's temperature is above his baseline temperature.
C)The client's temperature is at his baseline temperature.
D)The client's temperature is fluctuating with each measurement.

Question 36

A client has a body temperature of 96°F and exhibits slurred speech and poor coordination. Which is the priority nursing diagnosis for this client?

A)Risk for Thermal Injury
B)Hyperthermia
C)Hypothermia
D)Risk for Imbalanced Body Temperature

Question 37

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

A)Expect the baby to shiver.
B)Keep the newborn's head covered with a hat.
C)Cover the newborn with a light sheet during afternoon naps.
D)Cover the newborn with minimal blankets when out of doors in temperatures in the 50s.