Concept 9: Thermoregulation My Nursing Test Banks

Concept 9: Thermoregulation

Test Bank

MULTIPLE CHOICE

1. The nursery nurse identifies a newborn at significant risk for hypothermic alteration in thermoregulation because the patient is

a.

large for gestational age.

b.

low birth weight.

c.

born at term.

d.

well nourished.

ANS: B

Low birth weight and poorly nourished infants (particularly premature infants) and children are at greatest risk for hypothermia. A large for gestational age infant would not be malnourished. An infant born at term is not considered at significant risk. A well nourished infant is not at significant risk.

REF: 84

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

2. A volunteer at the senior center asks the visiting nurse why the senior citizens always seem to be complaining about temperatures. The nurses best response is that older people have a diminished ability to regulate body temperature because of

a.

active sweat glands.

b.

increased circulation.

c.

peripheral vasoconstriction.

d.

slower metabolic rates.

ANS: D

Slower metabolic rates are one factor that reduces the ability of older adults to regulate temperature and be comfortable when there are any temperature changes. As the body ages, the sweat glands decrease in number and efficiency. Older adults have reduced circulation. The body conserves heat through peripheral vasoconstriction, and older adults have a decreased vasoconstrictive response, which impacts ability to respond to temperature changes.

REF: 84

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

3. The nurse admitting a patient to the emergency department on a very hot summer day would suspect hyperthermia when the patient demonstrates

a.

decreased respirations.

b.

low pulse rate.

c.

red, sweaty skin.

d.

slow capillary refill.

ANS: C

With hyperthermia, vasodilatation occurs causing the skin to appear flushed and warm or hot to touch. There is an increased respiration rate with hyperthermia. The heart rate increases with hyperthermia. With hypothermia there is slow capillary refill.

REF: 86

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. The priority nursing intervention for a patient suspected to be hypothermic would be to

a.

assess vital signs.

b.

hydrate with intravenous (IV) fluids.

c.

provide a warm blanket.

d.

remove wet clothes.

ANS: D

The first thing to do with a patient suspected to be hypothermic is to remove wet clothes, because heat loss is five times greater when clothing is wet. Assessing vital signs is important, but the wet clothes should be removed first. Hydration is very important with hyperthermia and the associated danger of dehydration, but there is not a similar risk with hypothermia. A warm blanket over wet clothes would not be an effective warming strategy.

REF: 84

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

5. Strategies to include in a community program for senior citizens related to dealing with cold winter temperatures would include

a.

avoiding hot beverages.

b.

shopping at an indoor mall.

c.

using a fan at low speed.

d.

walking slowly in the park.

ANS: B

Shopping indoors where there is protection from the elements and temperature control is one strategy to avoid cold temperatures. Hot beverages can help an individual deal with cold weather. Avoiding breezes and air currents is recommended to conserve body temperature. Physical activity can increase body temperature, and if the senior is going to walk in the park, weather-appropriate (warm) clothing and a usual or brisk pace, not a slow pace, would be recommended.

REF: 84|88

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

6. During orientation to an emergency department, the nurse educator would be concerned if the new nurse listed which of the following as a risk factor for impaired thermoregulation?

a.

Impaired cognition

b.

Occupational exposure

c.

Physical agility

d.

Temperature extremes

ANS: C

Physical agility is not a risk factor for impaired thermoregulation. The nurse educator would use this information to plan additional teaching to include medical conditions and gait disturbance as risk factors for hypothermia, because their bodies have a reduced ability to generate heat. Impaired cognition is a risk factor. Recreational or occupational exposure is a risk factor. Temperature extremes are risk factors for impaired thermoregulation.

REF: 84-85

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

7. The most appropriate measure for a nurse to use in assessing core body temperature when there are suspected problems with thermoregulation is a(n)

a.

oral thermometer.

b.

rectal thermometer.

c.

temporal thermometer scan.

d.

tympanic membrane sensor.

ANS: B

The most reliable means available for assessing core temperature is a rectal temperature, which is considered the standard of practice. An oral temperature is a common measure but not the most reliable. A temporal thermometer scan has some limitations and is not the standard. The tympanic membrane sensor could be used as a second source for temperature assessment.

REF: 87

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

8. The nurse planning care for a patient with hypothermia would consider knowledge of similar exemplars including

a.

heat exhaustion.

b.

heat stroke.

c.

infection.

d.

prematurity.

ANS: D

Prematurity, frost bite, environmental exposure, and brain injury are considered exemplars of hypothermia. Heat exhaustion is an exemplar of hyperthermia. Heat stroke is an exemplar of hyperthermia. Infection is an exemplar of hyperthermia.

REF: 90

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

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