Question 1

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 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.

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 3

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)The diagnostic tests will focus on trying to find the cause of the elevated body temperature. The complete blood count will be done to see if there is an elevation in white blood cells, indicative of infection. A bone scan, a glucose tolerance test, and a CT scan of the abdomen may or may not be indicated for this client.
B)The diagnostic tests will focus on trying to find the cause of the elevated body temperature. The complete blood count will be done to see if there is an elevation in white blood cells, indicative of infection. A bone scan, a glucose tolerance test, and a CT scan of the abdomen may or may not be indicated for this client.
C)The diagnostic tests will focus on trying to find the cause of the elevated body temperature. The complete blood count will be done to see if there is an elevation in white blood cells, indicative of infection. A bone scan, a glucose tolerance test, and a CT scan of the abdomen may or may not be indicated for this client.
D)The diagnostic tests will focus on trying to find the cause of the elevated body temperature. The complete blood count will be done to see if there is an elevation in white blood cells, indicative of infection. A bone scan, a glucose tolerance test, and a CT scan of the abdomen may or may not be indicated for this client.

Question 4

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

Accepted Answer

A)Increased respiratory rate always occurs with a fever. Every one degree of temperature elevation causes an increase in respiratory rate of four breaths per minute. Prostaglandin production increases, not decreases, during fever.
B)Increased respiratory rate always occurs with a fever. Every one degree of temperature elevation causes an increase in respiratory rate of four breaths per minute. Prostaglandin production increases, not decreases, during fever.
C)Increased respiratory rate always occurs with a fever. Every one degree of temperature elevation causes an increase in respiratory rate of four breaths per minute. Prostaglandin production increases, not decreases, during fever.
D)Increased respiratory rate always occurs with a fever. Every one degree of temperature elevation causes an increase in respiratory rate of four breaths per minute. Prostaglandin production increases, not decreases, during fever.

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?

Accepted Answer

A)Conduction is the process of heat transfer through physical contact of one surface to another surface. This is the method of heat loss that occurs when a newborn baby is placed on a bare surface. Convection is the process of heat transfer through the fluid motion of air or water across the skin. Evaporation is the process of converting water to a vapor. Radiation is the process of heat transfer with no physical contact.
B)Conduction is the process of heat transfer through physical contact of one surface to another surface. This is the method of heat loss that occurs when a newborn baby is placed on a bare surface. Convection is the process of heat transfer through the fluid motion of air or water across the skin. Evaporation is the process of converting water to a vapor. Radiation is the process of heat transfer with no physical contact.
C)Conduction is the process of heat transfer through physical contact of one surface to another surface. This is the method of heat loss that occurs when a newborn baby is placed on a bare surface. Convection is the process of heat transfer through the fluid motion of air or water across the skin. Evaporation is the process of converting water to a vapor. Radiation is the process of heat transfer with no physical contact.
D)Conduction is the process of heat transfer through physical contact of one surface to another surface. This is the method of heat loss that occurs when a newborn baby is placed on a bare surface. Convection is the process of heat transfer through the fluid motion of air or water across the skin. Evaporation is the process of converting water to a vapor. Radiation is the process of heat transfer with no physical contact.

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?

Accepted Answer

A)Antipyretic medication is used to reduce the body temperature. Antihypertensives are used to reduce blood pressure. Antiemetics are used to reduce nausea and vomiting. Anticholinergics reduce acetylcholine activity.
B)Antipyretic medication is used to reduce the body temperature. Antihypertensives are used to reduce blood pressure. Antiemetics are used to reduce nausea and vomiting. Anticholinergics reduce acetylcholine activity.
C)Antipyretic medication is used to reduce the body temperature. Antihypertensives are used to reduce blood pressure. Antiemetics are used to reduce nausea and vomiting. Anticholinergics reduce acetylcholine activity.
D)Antipyretic medication is used to reduce the body temperature. Antihypertensives are used to reduce blood pressure. Antiemetics are used to reduce nausea and vomiting. Anticholinergics reduce acetylcholine activity.

Question 7

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

Accepted Answer

A)A goal of care for a client receiving antibiotic therapy for an infection is for the temperature to be within normal limits within 48 to 72 hours after starting the antibiotic. The temperature approaching normal within 60 minutes would be an appropriate goal if the client were receiving antipyretics. Sweating is evidence that the temperature is decreasing, a desired outcome. Dry mucous membranes are evidence of an elevated temperature and are not a desired outcome.
B)A goal of care for a client receiving antibiotic therapy for an infection is for the temperature to be within normal limits within 48 to 72 hours after starting the antibiotic. The temperature approaching normal within 60 minutes would be an appropriate goal if the client were receiving antipyretics. Sweating is evidence that the temperature is decreasing, a desired outcome. Dry mucous membranes are evidence of an elevated temperature and are not a desired outcome.
C)A goal of care for a client receiving antibiotic therapy for an infection is for the temperature to be within normal limits within 48 to 72 hours after starting the antibiotic. The temperature approaching normal within 60 minutes would be an appropriate goal if the client were receiving antipyretics. Sweating is evidence that the temperature is decreasing, a desired outcome. Dry mucous membranes are evidence of an elevated temperature and are not a desired outcome.
D)A goal of care for a client receiving antibiotic therapy for an infection is for the temperature to be within normal limits within 48 to 72 hours after starting the antibiotic. The temperature approaching normal within 60 minutes would be an appropriate goal if the client were receiving antipyretics. Sweating is evidence that the temperature is decreasing, a desired outcome. Dry mucous membranes are evidence of an elevated temperature and are not a desired outcome.

Question 8

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

Accepted Answer

A)Increased thyroxine levels cause an increase in the release of epinephrine. Norepinephrine does not cause epinephrine release. Progesterone maintains pregnancy and aldosterone regulates electrolyte and water balance; neither is involved in chemical thermogenesis.
B)Increased thyroxine levels cause an increase in the release of epinephrine. Norepinephrine does not cause epinephrine release. Progesterone maintains pregnancy and aldosterone regulates electrolyte and water balance; neither is involved in chemical thermogenesis.
C)Increased thyroxine levels cause an increase in the release of epinephrine. Norepinephrine does not cause epinephrine release. Progesterone maintains pregnancy and aldosterone regulates electrolyte and water balance; neither is involved in chemical thermogenesis.
D)Increased thyroxine levels cause an increase in the release of epinephrine. Norepinephrine does not cause epinephrine release. Progesterone maintains pregnancy and aldosterone regulates electrolyte and water balance; neither is involved in chemical thermogenesis.

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?

Accepted Answer

A)Convection is the process of heat transfer through the fluid motion of air or water across the skin. The clients of a boating accident developed hypothermia through convection. Evaporation is the process of converting water to a vapor, and the evaporation of sweat transfers the heat in the sweat to the air. Insensible water loss is unnoticed water loss through evaporation. Insensible heat loss is the loss of heat through evaporation.
B)Convection is the process of heat transfer through the fluid motion of air or water across the skin. The clients of a boating accident developed hypothermia through convection. Evaporation is the process of converting water to vapor, and the evaporation of sweat transfers the heat in the sweat to the air. Insensible water loss is unnoticed water loss through evaporation. Insensible heat loss is the loss of heat through evaporation.
C)Convection is the process of heat transfer through the fluid motion of air or water across the skin. The clients of a boating accident developed hypothermia through convection. Evaporation is the process of converting water to a vapor, and the evaporation of sweat transfers the heat in the sweat to the air. Insensible water loss is unnoticed water loss through evaporation. Insensible heat loss is the loss of heat through evaporation.
D)Convection is the process of heat transfer through the fluid motion of air or water across the skin. The clients of a boating accident developed hypothermia through convection. Evaporation is the process of converting water to a vapor, and the evaporation of sweat transfers the heat in the sweat to the air. Insensible water loss is unnoticed water loss through evaporation. Insensible heat loss is the loss of heat through evaporation.

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.

Accepted Answer

A)Evidence that interventions have been effective for a client with an elevated body temperature includes moist mucous membranes and good skin turgor. Urine output of 20 mL/hour indicates dehydration. Blood pressure of 118/68 mmHg is not an indication of the control of fever. A heart rate of 120 beats per minute could indicate dehydration.
B)Evidence that interventions have been effective for a client with an elevated body temperature includes moist mucous membranes and good skin turgor. Urine output of 20 mL/hour indicates dehydration. Blood pressure of 118/68 mmHg is not an indication of the control of fever. A heart rate of 120 beats per minute could indicate dehydration.
C)Evidence that interventions have been effective for a client with an elevated body temperature includes moist mucous membranes and good skin turgor. Urine output of 20 mL/hour indicates dehydration. Blood pressure of 118/68 mmHg is not an indication of the control of fever. A heart rate of 120 beats per minute could indicate dehydration.
D)Evidence that interventions have been effective for a client with an elevated body temperature includes moist mucous membranes and good skin turgor. Urine output of 20 mL/hour indicates dehydration. Blood pressure of 118/68 mmHg is not an indication of the control of fever. A heart rate of 120 beats per minute could indicate dehydration.
E)Evidence that interventions have been effective for a client with an elevated body temperature includes moist mucous membranes and good skin turgor. Urine output of 20 mL/hour indicates dehydration. Blood pressure of 118/68 mmHg is not an indication of the control of fever. A heart rate of 120 beats per minute could indicate dehydration.

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 indicate 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 indicate 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 indicate 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 indicate infection. The client was not exercising. Diet does not influence body temperature.

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?

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 14

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

Accepted Answer

A)Hyperthermia is the medical term for an increase in body temperature. An appropriate intervention for a client experiencing hyperthermia is to administer a prescribed antipyretic medication, such as acetaminophen. Applying warm blankets, keeping the limbs close to the body, and covering the scalp with a hat are all appropriate interventions for a client who is experiencing hypothermia.
B)Hyperthermia is the medical term for an increase in body temperature. An appropriate intervention for a client experiencing hyperthermia is to administer a prescribed antipyretic medication, such as acetaminophen. Applying warm blankets, keeping the limbs close to the body, and covering the scalp with a hat are all appropriate interventions for a client who is experiencing hypothermia.
C)Hyperthermia is the medical term for an increase in body temperature. An appropriate intervention for a client experiencing hyperthermia is to administer a prescribed antipyretic medication, such as acetaminophen. Applying warm blankets, keeping the limbs close to the body, and covering the scalp with a hat are all appropriate interventions for a client who is experiencing hypothermia.
D)Hyperthermia is the medical term for an increase in body temperature. An appropriate intervention for a client experiencing hyperthermia is to administer a prescribed antipyretic medication, such as acetaminophen. Applying warm blankets, keeping the limbs close to the body, and covering the scalp with a hat are all appropriate interventions for a client who is experiencing hypothermia.

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?

Accepted Answer

A)Older adults' temperatures may not be a valid indication of an infectious process. Other symptoms such as confusion and restlessness may be a more accurate indicator. A normal body temperature does not indicate that the client does not have pneumonia. The client may or may not be losing body heat. It is not known whether the room is or is not cold.
B)Older adults' temperatures may not be a valid indication an infectious process. Other symptoms such as confusion and restlessness may be a more accurate indicator. A normal body temperature does not indicate that the client does not have pneumonia. The client may or may not be losing body heat. It is not known whether the room is or is not cold.
C)Older adults' temperatures may not be a valid indication of an infectious process. Other symptoms such as confusion and restlessness may be a more accurate indicator. A normal body temperature does not indicate that the client does not have pneumonia. The client may or may not be losing body heat. It is not known whether the room is or is not cold.
D)Older adults' temperatures may not be a valid indication of an infectious process. Other symptoms such as confusion and restlessness may be a more accurate indicator. A normal body temperature does not indicate that the client does not have pneumonia. The client may or may not be losing body heat. It is not known whether the room is or is not cold.

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?

Accepted Answer

A)Fever is not inherently harmful until it reaches 41°C (105.9°F). For this reason, medical management may include postponing treatment of low-grade fevers-those under 38.9°C (102°F)in otherwise healthy children. The child may be placed in a tepid, not cold, bath. Aspirin should not be given to children due to its link to Reye syndrome. Reducing clothing and blankets, not additional layers, aids in the treatment of fever.
B)Fever is not inherently harmful until it reaches 41°C (105.9°F). For this reason, medical management may include postponing treatment of low-grade fevers-those under 38.9°C (102°F)in otherwise healthy children. The child may be placed in a tepid, not cold, bath. Aspirin should not be given to children due to its link to Reye syndrome. Reducing clothing and blankets, not additional layers, aids in the treatment of fever.
C)Fever is not inherently harmful until it reaches 41°C (105.9°F). For this reason, medical management may include postponing treatment of low-grade fevers-those under 38.9°C (102°F)in otherwise healthy children. The child may be placed in a tepid, not cold, bath. Aspirin should not be given to children due to its link to Reye syndrome. Reducing clothing and blankets, not additional layers, aids in the treatment of fever.
D)Fever is not inherently harmful until it reaches 41°C (105.9°F). For this reason, medical management may include postponing treatment of low-grade fevers-those under 38.9°C (102°F)in otherwise healthy children. The child may be placed in a tepid, not cold, bath. Aspirin should not be given to children due to its link to Reye syndrome. Reducing clothing and blankets, not additional layers, aids in the treatment of fever.

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

Accepted Answer

A)Hypothermia occurs when core body temperature is below 95°F and is classified as moderate between 82.4°F and 89.6°F. Normothermia occurs when body temperature falls between 96.8°F and 101.3°F. Hyperthermia occurs when body temperature is above 101.3°F. A hyperthermic patient may be described as febrile.
B)Hypothermia occurs when core body temperature is below 95°F and is classified as moderate between 82.4°F and 89.6°F. Normothermia occurs when body temperature falls between 96.8°F and 101.3°F. Hyperthermia occurs when body temperature is above 101.3°F. A hyperthermic patient may be described as febrile.
C)Hypothermia occurs when core body temperature is below 95°F and is classified as moderate between 82.4°F and 89.6°F. Normothermia occurs when body temperature falls between 96.8°F and 101.3°F. Hyperthermia occurs when body temperature is above 101.3°F. A hyperthermic patient may be described as febrile.
D)Hypothermia occurs when core body temperature is below 95°F and is classified as moderate between 82.4°F and 89.6°F. Normothermia occurs when body temperature falls between 96.8°F and 101.3°F. Hyperthermia occurs when body temperature is above 101.3°F. A hyperthermic patient may be described as febrile.

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.

Accepted Answer

A)The client has an elevated temperature. The administration of antipyretic medication is one treatment used to lower the body temperature. Increasing fluid intake is another intervention for an elevated body temperature. The other options would be interventions to help a client with a low body temperature.
B)The client has an elevated temperature. The administration of antipyretic medication is one treatment used to lower the body temperature. Increasing fluid intake is another intervention for an elevated body temperature. The other options would be interventions to help a client with a low body temperature.
C)The client has an elevated temperature. The administration of antipyretic medication is one treatment used to lower the body temperature. Increasing fluid intake is another intervention for an elevated body temperature. The other options would be interventions to help a client with a low body temperature.
D)The client has an elevated temperature. The administration of antipyretic medication is one treatment used to lower the body temperature. Increasing fluid intake is another intervention for an elevated body temperature. The other options would be interventions to help a client with a low body temperature.
E)The client has an elevated temperature. The administration of antipyretic medication is one treatment used to lower the body temperature. Increasing fluid intake is another intervention for an elevated body temperature. The other options would be interventions to help a client with a low body temperature.

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?

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 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.

Accepted Answer

A)Until the client has orders written, the nurse can apply cool washcloths to the client's face and neck to increase comfort and reduce the client's body temperature. The nurse can also reduce clothing and skin covering by loosening clothing around the neck and chest. Warm blankets and fluid restriction would keep the temperature elevated rather than helping to decrease it. Assessing vital signs is important; however, the nurse needs to intervene to help bring the body temperature down.
B)Until the client has orders written, the nurse can apply cool washcloths to the client's face and neck to increase comfort and reduce the client's body temperature. The nurse can also reduce clothing and skin covering by loosening clothing around the neck and chest. Warm blankets and fluid restriction would keep the temperature elevated rather than helping to decrease it. Assessing vital signs is important; however, the nurse needs to intervene to help bring the body temperature down.
C)Until the client has orders written, the nurse can apply cool washcloths to the client's face and neck to increase comfort and reduce the client's body temperature. The nurse can also reduce clothing and skin covering by loosening clothing around the neck and chest. Warm blankets and fluid restriction would keep the temperature elevated rather than helping to decrease it. Assessing vital signs is important; however, the nurse needs to intervene to help bring the body temperature down.
D)Until the client has orders written, the nurse can apply cool washcloths to the client's face and neck to increase comfort and reduce the client's body temperature. The nurse can also reduce clothing and skin covering by loosening clothing around the neck and chest. Warm blankets and fluid restriction would keep the temperature elevated rather than helping to decrease it. Assessing vital signs is important; however, the nurse needs to intervene to help bring the body temperature down.
E)Until the client has orders written, the nurse can apply cool washcloths to the client's face and neck to increase comfort and reduce the client's body temperature. The nurse can also reduce clothing and skin covering by loosening clothing around the neck and chest. Warm blankets and fluid restriction would keep the temperature elevated rather than helping to decrease it. Assessing vital signs is important; however, the nurse needs to intervene to help bring the body temperature down.

Quiz 20: Thermoregulation