Question 1

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?

Accepted Answer

A)During the flush phase of a fever, the client's body is attempting to adjust the temperature set-point lower. Nursing measures are implemented in order to aid the body in reestablishing a core temperature compatible with normal cellular functioning. The nurse must diligently monitor the client's intake and output to addresses changes in hydration state. Restricting fluids could lead to dehydration and a higher body temperature. Warm blankets and warm intravenous fluids will increase the body's temperature.
B)During the flush phase of a fever, the client's body is attempting to adjust the temperature set-point lower. Nursing measures are implemented in order to aid the body in reestablishing a core temperature compatible with normal cellular functioning. The nurse must diligently monitor the client's intake and output to address changes in hydration state. Restricting fluids could lead to dehydration and a higher body temperature. Warm blankets and warm intravenous fluids will increase the body's temperature.
C)During the flush phase of a fever, the client's body is attempting to adjust the temperature set-point lower. Nursing measures are implemented in order to aid the body in reestablishing a core temperature compatible with normal cellular functioning. The nurse must diligently monitor the client's intake and output to address changes in hydration state. Restricting fluids could lead to dehydration and a higher body temperature. Warm blankets and warm intravenous fluids will increase the body's temperature.
D)During the flush phase of a fever, the client's body is attempting to adjust the temperature set-point lower. Nursing measures are implemented in order to aid the body in reestablishing a core temperature compatible with normal cellular functioning. The nurse must diligently monitor the client's intake and output to address changes in hydration state. Restricting fluids could lead to dehydration and a higher body temperature. Warm blankets and warm intravenous fluids will increase the body's temperature.

Question 2

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?

Accepted Answer

Older adults often do not mount the same fever response to infections as younger adults due to changes in the body's ability to respond to changes in temperature. This is why the client can have an infection without having a fever. The other answer choices are incorrect and/or inappropriate.

Question 3

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

Accepted Answer

Thyroxine is the hormone responsible for increasing metabolism and promoting the release of epinephrine, which in turn leads to chemical thermogenesis. Norepinephrine acts as a neurotransmitter and is involved in the body's "fight or flight" response, but it is not directly responsible for chemical thermogenesis. Progesterone and aldosterone are not involved in thermogenesis.

Question 4

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?

Accepted Answer

By spreading a cotton pad over the exam table, the nurse is protecting against heat loss through conduction, which is the transfer of heat from a warmer object to a cooler object by direct contact. The cotton pad acts as a barrier between the baby and the cold exam table, helping to reduce heat loss. Convection is the transfer of heat through the movement of air or liquid, evaporation is the process of a liquid changing into a gas, and radiation is the transfer of heat through electromagnetic waves. While these methods can also contribute to heat loss in a newborn, they are not directly addressed by the nurse's action of spreading a cotton pad on the exam table.

Question 5

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.

Accepted Answer

A)The client with an elevated body temperature should be encouraged to ingest fluids or should be provided with IV fluids. The increase in body temperature could be due to dehydration. Another intervention to help the client with an elevated temperature is to lower the room temperature. The client's fluids should not be restricted. Blankets and providing a warm room would be applicable if the client had a low body temperature.
B)The client with an elevated body temperature should be encouraged to ingest fluids or should be provided with IV fluids. The increase in body temperature could be due to dehydration. Another intervention to help the client with an elevated temperature is to lower the room temperature. The client's fluids should not be restricted. Blankets and providing a warm room would be applicable if the client had a low body temperature.
C)The client with an elevated body temperature should be encouraged to ingest fluids or should be provided with IV fluids. The increase in body temperature could be due to dehydration. Another intervention to help the client with an elevated temperature is to lower the room temperature. The client's fluids should not be restricted. Blankets and providing a warm room would be applicable if the client had a low body temperature.
D)The client with an elevated body temperature should be encouraged to ingest fluids or should be provided with IV fluids. The increase in body temperature could be due to dehydration. Another intervention to help the client with an elevated temperature is to lower the room temperature. The client's fluids should not be restricted. Blankets and providing a warm room would be applicable if the client had a low body temperature.
E)The client with an elevated body temperature should be encouraged to ingest fluids or should be provided with IV fluids. The increase in body temperature could be due to dehydration. Another intervention to help the client with an elevated temperature is to lower the room temperature. The client's fluids should not be restricted. Blankets and providing a warm room would be applicable if the client had a low body temperature.

Question 6

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?

Accepted Answer

Convection is the transfer of heat between an object and a fluid medium, such as air or water. In this case, the boating accident likely caused the client to be immersed in cold water, leading to heat loss via convection and ultimately resulting in hypothermia.

Question 7

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

Accepted Answer

Hyperthermia is an elevation of body temperature above the normal range. Antipyretic medications help to reduce fever by reversing the effects of pyrogens on the hypothalamus. Applying warm blankets, keeping limbs close to the body, and covering the scalp with a hat will further increase the body temperature and worsen the condition.

Question 8

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

Accepted Answer

A complete blood count (CBC) is a basic diagnostic test that is often ordered when a client presents with a fever of unknown origin. The CBC provides information about the number and types of blood cells in the body, which can give clues about the underlying cause of the fever. CT scan of the abdomen, bone scan, and glucose tolerance test may also be ordered in some cases, but the CBC is the most common initial diagnostic test.

Question 9

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.

Accepted Answer

The client is showing signs of hyperthermia and needs to be cooled down. Applying cool washcloths to the face and neck and removing or loosening clothing around the neck and chest will help to dissipate heat. Using warm blankets would only increase the client's body temperature. Fluids should be encouraged to prevent dehydration. Vital signs should be assessed to monitor the client's condition.

Question 10

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

Accepted Answer

One degree of temperature elevation causes an increase in respiratory rate by four breaths per minute, which is known as tachypnea. This is due to an increased metabolic rate and oxygen demand in the body. Additionally, fever is often associated with an increase in prostaglandin production, which can also stimulate the respiratory center in the brain and contribute to tachypnea.

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?

Accepted Answer

A)College students are mostly likely to pay attention to a video compared to other media choices, and showing a video about the harmful effects of hypothermia due to exposure may be effective for many students who wouldn't pay attention to the other options. College students are likely to ignore posters telling them to wear hats and mittens. Alcohol consumption increases the risk of exposure due to poor choices, which then increases the risk for hypothermia. Students may not have money to purchase handwarmers, and they may not even know they are available for purchase in the bookstore without some advertisement.
B)College students are mostly likely to pay attention to a video compared to other media choices, and showing a video about the harmful effects of hypothermia due to exposure may be effective for many students that wouldn't pay attention to the other options. College students are likely to ignore posters telling them to wear hats and mittens. Alcohol consumption increases the risk of exposure due to poor choices, which then increases the risk for hypothermia. Students may not have money to purchase handwarmers, and they may not even know they are available for purchase in the bookstore without some advertisement.
C)College students are mostly likely to pay attention to a video compared to other media choices, and showing a video about the harmful effects of hypothermia due to exposure may be effective for many students that wouldn't pay attention to the other options. College students are likely to ignore posters telling them to wear hats and mittens. Alcohol consumption increases the risk of exposure due to poor choices, which then increases the risk for hypothermia. Students may not have money to purchase handwarmers, and they may not even know they are available for purchase in the bookstore without some advertisement.
D)College students are mostly likely to pay attention to a video compared to other media choices, and showing a video about the harmful effects of hypothermia due to exposure may be effective for many students that wouldn't pay attention to the other options. College students are likely to ignore posters telling them to wear hats and mittens. Alcohol consumption increases the risk of exposure due to poor choices, which then increases the risk for hypothermia. Students may not have money to purchase handwarmers, and they may not even know they are available for purchase in the bookstore without some advertisement.

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?

Accepted Answer

A) Factors that affect body temperature include age, diurnal variations, exercise, hormones, stress, and environment. The client who is a victim of an industrial accident most likely has a temperature elevation because of stress. There is no evidence presented to suspect infection. The client was not exercising. Diet does not influence body temperature.
B) Factors that affect body temperature include age, diurnal variations, exercise, hormones, stress, and environment. The client who is a victim of an industrial accident most likely has a temperature elevation because of stress. There is no evidence presented to suspect infection. The client was not exercising. Diet does not influence body temperature.
C) Factors that affect body temperature include age, diurnal variations, exercise, hormones, stress, and environment. The client who is a victim of an industrial accident most likely has a temperature elevation because of stress. There is no evidence presented to suspect infection. The client was not exercising. Diet does not influence body temperature.
D) Factors that affect body temperature include age, diurnal variations, exercise, hormones, stress, and environment. The client who is a victim of an industrial accident most likely has a temperature elevation because of stress. There is no evidence presented to suspect infection. The client was not exercising. Diet does not influence body temperature.

Question 13

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?

Accepted Answer

A temperature of 101°F with a normal appearance and few signs of discomfort is considered a low-grade fever and usually does not require treatment unless the child is uncomfortable. Cold baths and the use of aspirin are no longer recommended for fever treatment in children due to potential complications. Additionally, using blankets to decrease discomfort may actually increase the child's temperature and should be avoided.

Question 14

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.

Accepted Answer

The client's plan of care should include increasing fluid intake to prevent dehydration due to the elevated temperature and administering antipyretic medication to help lower the fever. Administering warm fluids and blankets and keeping limbs close to the body would not be appropriate interventions for a client with an elevated temperature.

Question 15

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

Accepted Answer

A core body temperature of 88.8°F indicates moderate hypothermia, which is defined as a body temperature below 95°F. This is a medical emergency that requires immediate intervention to prevent complications such as cardiac arrest, respiratory failure, and neurological damage.

Question 16

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?

Accepted Answer

A) Since the oral method cannot be used because the client smoked a cigarette and consumed hot coffee, the assessment method of choice would be the tympanic membrane. This method is readily accessible and reflects the core temperature very quickly. The rectal method is inconvenient and uncomfortable for clients. The temporal artery method requires special electronic equipment. The axillary method takes a long time if an accurate measurement is to be obtained.
B) Since the oral method cannot be used because the client smoked a cigarette and consumed hot coffee, the assessment method of choice would be the tympanic membrane. This method is readily accessible and reflects the core temperature very quickly. The rectal method is inconvenient and uncomfortable for clients. The temporal artery method requires special electronic equipment. The axillary method takes a long time if an accurate measurement is to be obtained.
C) Since the oral method cannot be used because the client smoked a cigarette and consumed hot coffee, the assessment method of choice would be the tympanic membrane. This method is readily accessible and reflects the core temperature very quickly. The rectal method is inconvenient and uncomfortable for clients. The temporal artery method requires special electronic equipment. The axillary method takes a long time if an accurate measurement is to be obtained.
D) Since the oral method cannot be used because the client smoked a cigarette and consumed hot coffee, the assessment method of choice would be the tympanic membrane. This method is readily accessible and reflects the core temperature very quickly. The rectal method is inconvenient and uncomfortable for clients. The temporal artery method requires special electronic equipment. The axillary method takes a long time if an accurate measurement is to be obtained.

Question 17

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

Accepted Answer

Moist mucous membranes and good skin turgor indicate that the client is adequately hydrated, which is important in managing elevated body temperature. A urine output of 20 mL/hour is lower than the desired amount of 30 mL/hour, indicating that the client may still be dehydrated. A heart rate of 120 beats per minute is elevated and may indicate that the body temperature is still high. A blood pressure of 118/68 mmHg is within normal range but does not specifically indicate the effectiveness of care for an elevated body temperature.

Question 18

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?

Accepted Answer

The client experiencing an elevated body temperature will likely be prescribed an antipyretic medication, which is specifically designed to reduce fever. Anticholinergics are used to treat a variety of conditions including overactive bladder, irritable bowel syndrome, and Parkinson's disease. Antihypertensives are used to treat high blood pressure, and antiemetics are used to treat nausea and vomiting. None of these medications are specifically designed to lower fever.

Question 19

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

Accepted Answer

A)All muscle activity, regardless of location, produces heat. Core temperature remains relatively constant, whereas the body's surface temperature varies widely depending on the outside environment. Chemical thermogenesis occurs with increased output of thyroxine, not cortisol.
B)All muscle activity, regardless of location, produces heat. Core temperature remains relatively constant, whereas the body's surface temperature varies widely depending on the outside environment. Chemical thermogenesis occurs with increased output of thyroxine, not cortisol.
C)All muscle activity, regardless of location, produces heat. Core temperature remains relatively constant, whereas the body's surface temperature varies widely depending on the outside environment. Chemical thermogenesis occurs with increased output of thyroxine, not cortisol.
D)All muscle activity, regardless of location, produces heat. Core temperature remains relatively constant, whereas the body's surface temperature varies widely depending on the outside environment. Chemical thermogenesis occurs with increased output of thyroxine, not cortisol.

Question 20

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

Accepted Answer

The appropriate goal for a client started on antibiotic therapy for a respiratory infection is for their temperature to be within normal limits within 48 to 72 hours of the administration of the antibiotic. It is unrealistic to expect the temperature to approach normal within 60 minutes of the administration of the antibiotic, as it takes time for the medication to take effect. Sweating is not a relevant parameter to measure in this situation, and dry mucous membranes are not necessarily a positive outcome.

Quiz 20: Thermoregulation