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:

Accepted Answer

Removing wet clothes prevents evaporative heat loss, as the evaporation of water from the clothes would otherwise draw heat away from the body.

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?

Accepted Answer

Wrapping the patient in warm blankets helps prevent convective heat loss, which occurs when heat is lost to the surrounding air. The blankets act as a barrier to the cold air, reducing 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?

Accepted Answer

Stage III of the Swiss Hypothermia Staging System is characterized by a core body temperature of 24-28°C, where the patient is unconscious and not shivering.

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?

Accepted Answer

Applying heat packs to the trunk is an appropriate intervention for rewarming a hypothermic patient, as it helps to increase core body temperature.

Question 5

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

Accepted Answer

Alcohol impairs judgment, which can lead to poor decision-making in cold environments, increasing the risk of hypothermia.

Question 6

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

Accepted Answer

Shivering occurs when the body's core temperature falls below the set point range, triggering mechanisms to generate heat and raise the body temperature.

Question 7

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

Accepted Answer

Newborns generate heat primarily through nonshivering thermogenesis, which involves the metabolism of brown adipose tissue.

Question 8

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

Accepted Answer

Older adults generally have a lower mean body mass and less subcutaneous fat, which can reduce their ability to retain heat, making them more susceptible to cold temperatures.

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:

Accepted Answer

Therapeutic hypothermia is a medical treatment that intentionally lowers the body temperature to reduce the risk of ischemic injury to tissue following a period of insufficient blood flow, such as after cardiac arrest.

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?

Accepted Answer

A bath outside the warmer can cause the newborn's body temperature to drop, increasing the risk of hypothermia, especially in a low birth-weight newborn.

Question 11

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

Accepted Answer

The answer of When caring for a patient with mild...

Question 12

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

Accepted Answer

J waves, also known as Osborn waves, are typically seen in patients with moderate hypothermia.

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:

Accepted Answer

The heart is irritable and susceptible to ventricular fibrillation at low body temperatures, such as 30°C, making gentle handling crucial to prevent cardiac arrhythmias.

Question 14

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

Accepted Answer

During the chill phase of fever, the body is trying to increase its temperature to the new set point, leading to shivering, vasoconstriction, and a sensation of feeling cold.

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?

Accepted Answer

Heat stroke is characterized by hot, flushed dry skin, confusion, and sometimes bradycardia due to the body's inability to regulate temperature and the failure of the sweating mechanism.

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:

Accepted Answer

Malignant hyperthermia is transmitted in an autosomal dominant pattern, meaning only one copy of the altered gene is sufficient to increase the risk of developing the condition.

Question 17

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

Accepted Answer

Second-degree frostbite is characterized by superficial clear fluid-filled blisters, indicating damage to the skin and underlying tissues.

Question 18

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

Accepted Answer

Profound hypothermia can lead to severe depression of neurological and cardiac function, resulting in absent neurological reflexes and asystole.

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?

Accepted Answer

The statement reflects a lack of understanding of the importance of checking on vulnerable populations, such as the homeless, who may not have access to shelters or choose not to use them, especially during extreme weather conditions.

Question 20

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

Accepted Answer

Patients with hypohidrotic ectodermal dysplasia have difficulty regulating body temperature due to reduced ability to sweat, making maintaining a safe body temperature a priority.

Quiz 33: Disorders of Thermoregulation