Deck 33: Disorders of Thermoregulation

Question 1

A patient in the emergency department fell through the ice on a pond and was rescued by friends and driven to the hospital, still in wet clothes. By removing the wet clothes, the nurse is preventing:

A) radiant heat loss.
B) evaporative heat loss.
C) convective heat loss.
D) conductive heat loss.

Answer 1

evaporative heat loss.

Question 2

After removing the wet clothing from a patient who fell through the ice into cold water, the nurse wraps the patient in warm blankets to prevent heat loss by which means?

A) Radiant heat loss
B) Evaporative heat loss
C) Convective heat loss
D) Conductive heat loss

Answer 2

Convective heat loss

Question 3

A patient who is unconscious, not shivering, and has a core body temperature of 25^oC is classified as which stage of the Swiss Hypothermia Staging System?

A) Stage I
B) Stage II
C) Stage III
D) Stage IV

Answer 3

Stage III

Question 4

A patient who was found in the snow with impaired consciousness, no shivering, and a body temperature of 33°C is being transported by life flight helicopter to a hospital with rewarming resources. Which interventions should the life flight nurse anticipate?

A) Giving warm beverages
B) Encouraging active movement
C) Applying heat packs to the trunk
D) Taking the time to stabilize at the scene before transporting to hospital

Question 5

In a community program, the community health nurse warns that alcohol increases the risk of hypothermia due to:

A) impaired judgement.
B) vasoconstriction.
C) hyperglycemia.
D) impaired shivering.

Question 6

When a patient with a febrile illness begins to shiver, the nurse understands that which of the following has occurred?

A) A rise in body temperature has been sensed by the central thermoreceptors.
B) A drop in body temperature has been sensed by the central thermoreceptors.
C) The core temperature has risen above the set point range.
D) The core temperature has fallen below the set point range.

Question 7

Through which mechanism is the newborn able to generate heat in a cool delivery room?

A) Shivering
B) Nonshivering thermogenesis
C) Voluntary skeletal muscle activity
D) Vasoconstriction

Question 8

Which concept should the nurse use to develop a community program teaching older adults about the hazards of cold winter temperatures?

A) Older adults have a higher metabolic rate.
B) Older adults have a lower mean body mass.
C) Older adults have a higher vasoconstrictor response.
D) Older adults have a higher ability to generate heat when cold.

Question 9

The nurse in the intensive care unit is caring for a patient whose body temperature has been cooled to decrease the oxygen requirement of the brain and heart. The nurse explains to the family that this treatment is called:

A) accidental hypothermia.
B) inadvertent hypothermia.
C) iatrogenic hypothermia.
D) therapeutic hypothermia.

Question 10

The nurse in the newborn intensive care unit is caring for a low birth-weight newborn, born at 36-weeks' gestation, who was delivered in a car en route to the hospital in a snowstorm. Which statement by a parent of the newborn indicates a lack of understanding of the risks of hypothermia?

A) "My baby is burning calories at a higher rate."
B) "My baby is under a radiant warmer because he doesn't have enough body fat to keep warm."
C) "Now that my baby is warmed, I can give him a bath outside the warmer."
D) "When my baby is out of the warmer, I need to keep him wrapped."

Question 11

When caring for a patient with mild hypothermia, which finding would the nurse expect?

A) Diuresis
B) Hypoventilation
C) Vasodilation
D) Bradycardia

Question 12

When assessing the electrocardiogram of a hypothermic patient, which finding signals that the patient has become moderately hypothermic?

A) Inverted T waves
B) J waves
C) Inverted P waves
D) U waves

Question 13

A patient who was found in the snow with impaired consciousness, no shivering, and a body temperature of 28°C is being transported by life flight helicopter to a hospital with rewarming resources. The patient warms to 30°C en route to the hospital, and the nurse cautions the team to move the patient gently, explaining that at this body temperature:

A) the bones are brittle and can fracture easily.
B) the skin is fragile and tears easily.
C) the heart is irritable and susceptible to ventricular fibrillation.
D) the muscles become rigid and can cause fractures and joint injury.

Question 14

The nurse should expect which manifestations in a patient in the chill phase of fever?

A) Shivering, vasoconstriction, report of feeling cold
B) No chills, no report of feeling distressed
C) Report of feeling uncomfortably hot, sweating
D) Hot dry skin, confusion

Question 15

When assessing a patient with a 40^oC core body temperature, which manifestations cause the nurse to determine that the patient has heat stroke?

A) Heavy sweating, excessive thirst, bradycardia
B) Nausea, weakness, sweating
C) Confusion, anxiety, sweating
D) Hot, flushed dry skin; bradycardia; confusion

Question 16

A patient asks the surgical nurse why the anesthesiologist asked if a member of his family ever had hyperthermia during surgery. The nurse responds that malignant hyperthermia is a life-threatening crisis that:

A) is transmitted in an autosomal recessive pattern.
B) is transmitted in an autosomal dominant pattern.
C) is an X-linked trait.
D) is caused by an extra chromosome.

Question 17

Which findings should the nurse expect in patient with second-degree frostbite in the fingers?

A) Hard white plaque on the fingertips
B) Superficial clear fluid-filled blisters
C) Deep purple fluid-filled blisters
D) No skin changes.

Question 18

The nurse should expect to assess which manifestations in a patient with profound hypothermia?

A) Absent neurological reflexes, asystole
B) Absent muscle reflexes, undetectable pulse
C) J-waves on ECG, exaggerated tendon reflexes
D) Agitation, vigorous shivering

Question 19

The nurse is teaching a community health program on the danger of extremes of hot and cold temperatures. Which statement by a participant indicates to the nurse that more teaching is needed?

A) "I need to check on my elderly neighbors during the winter."
B) "I need to make sure my elderly parents are drinking enough and staying cool in the summer."
C) "We should make sure the homeless have shelter in extremes of weather."
D) "There are homeless shelters, so why do we need to check on those who chose to sleep in the park?"

Question 20

Which of the following problems would be a priority in the nursing care plan for a patient with hypohidrotic ectodermal dysplasia?

A) Maintaining an open airway
B) Ensuring adequate nutrition
C) Maintaining a safe body temperature
D) Reducing the risk for bleeding