Thermoregulation NCLEX style Questions

Thermoregulation NCLEX style Questions 4.6 (12 reviews) Students also studied Terms in this set (14) Germanna Community College NSG 200 Save NCLEX Thermoregulation Questions...27 terms nannabrooke11 Preview Chapter 25 - Thermoregulation NCL...15 terms Heather_Westbury Preview NCLEX Thermoregulation Questions...12 terms missangela4Preview Patho E 15 terms loe The nurse is listing consequences of malignant hyperthermia. Which consequences should be included?(select all that apply)

• Disseminated intravascular coagulation
• Renal failure
• Cardiac dysrhythmias
• Gastroenteritis
• Pulmonary edema
• Disseminated intravascular coagulation
• Renal failure
• Cardiac dysrhythmias
• Pulmonary edema

Which type of body temperature changes in response to the environment?

• core
• metabolic
• surface
• physiologic
• Surface

The nurse observes a mother stroking her​ child's arms and legs with a​ cool, damp washcloth. Which method of heat transfer is the mother using to reduce the​ fever?

• Radiation
• Evaporation
• Conduction
• Metabolism
• Evaporation

Rationale: Heat can be transferred between places or objects. Evaporation is the conversion of water to​ vapor, which is what occurs when the mother applies cool water to the​ child's limbs. Radiation is the release of heat through no physical contact. Conduction is the release of heat through physical contact. Metabolism is not a method of heat transfer

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?

• "Your body temperature fluctuates​ significantly, so a

true temperature is difficult to​ obtain."

• "I will to take your temperature​ rectally, since it is the

only reliable route in somebody your​ age."

• "The true temperature will not register because you

are a mouth​ breather."

• "Body temperature in an older adult is not a reliable

indicator of the seriousness of an​ illness."

• "Body temperature in an older adult is not a reliable indicator of the seriousness

of an illness." ​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 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.)

• Sweating
• Cold hands
• Thirst
• Shivering
• Sleepiness
• Cold hands
• shivers

​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.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?

• Malignant hyperthermia
• Heat stroke
• Hypothermia
• Normothermia
• Heat stroke

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, 32dash-​35°C ​(89.6dash-​95°F); ​moderate, 28dash-​32°C ​(82.4dash-​ 89.6°F), or​ severe, below​ 28°C (less than​ 82.4°F). The usual range of core body temperature is called normothermia. The normal range for adults is between​ 36°C and​ 38.5°C (96.8°F and​ 101.3°F). Malignant hyperthermia is a potentially​ fatal, inherited disorder that results from the​ body's reaction to volatile inhalation of anesthetic gases and​ succinylcholine, a depolarizing neuromuscular blocker.The nurse is preparing to use the tympanic membrane to measure the temperature of a​ 4-year-old child. Which approach should the nurse take when completing this​ measurement?

• Pull the earlobe back and up.
• Pull the pinna back and down.
• Pull the pinna back and up.
• Pull the earlobe back and down.
• pull the pinna back and up

​Rationale: The pinna is pulled straight back and upward when taking temperature in children over 3 years of age. To measure temperature using the tympanic membrane in an​ infant, the pinna is pulled straight back and slightly downward.The earlobe is not manipulated to measure temperature using the tympanic membrane.Which is a noninvasive method that the nurse uses to assess a​ client's temperature?​ (Select all that​ apply.)

• Axillary
• Rectal
• Oral
• Temporal artery
• Tympanic membrane
• Axillary
• Temporal Artery

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.)

• Urinary
• Musculoskeletal
• Respiratory
• Gastrointestinal
• Neurologic
• Urinary
• Respiratory
• Gastrointestinal

​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 provided teaching to an older adult client about fevers. Which client statement indicates that the teaching was​ effective?

• "The rectal route is the best way to have my

temperature​ taken."

• "I may not have a fever when I get sick or have an​

infection."

• "I am less sensitive to environmental temperatures than

when I was​ younger."

• "Cancer is the top source of fever in older​ adults."
• "I may not have a fever when I get sick or have an infection."

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.The nurse is evaluating teaching provided to the parents of​ 2-year-old twins regarding temperature measurement devices in the home. Which observation indicates that teaching has been​ effective? (Select all that​ apply.)

• Separate mercury glass thermometers are available for

each child.

• There is no evidence of a​ temperature-measuring

device in the home.

• Mercury glass thermometers are removed from the

home.

• An electronic thermometer with disposable covers is

available for use.

• Pad and pencil are placed next to the​ temperature-

measuring device.

• Mercury glass thermometers are removed from the home
• an electronic thermometer with disposable covers is available for use
• Pad and pencil are placed next to the thermometer measuring device

The nurse is preparing a presentation to parents about vehicle safety and​ heat-related injuries. Which important teaching point should be​ included?

• Keep important articles in the backseat to ensure

checking the area before leaving the vehicle.

• Store car keys in a visible place and within the​

children's reach in case of an emergency.

• Leave a child alone in the car only if the outside

temperature is below 80degrees°F.

• Stay with a child in the car for up to 10 minutes with the

windows cracked open.

• Keep important articles in the backseat to ensure checking the area before

leaving the vehicle

​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.

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?

• Cancel athletic games when the temperature is above

80degrees°F.

• Reduce athletic activities at the school.
• Increase access to​ fresh, cold water.
• Encourage the school to move athletic activities

indoors.

• Increase access to fresh, cold water

​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​?

• Help the guest get​ inside, and call 911.
• Run inside and call 911.
• Send someone to call 911 and stay with the guest.
• Remove clothing and lightly mist the guest with cool

water.