ch 10 Flashcards
Which newborn should the nursery nurse identify as being at significant risk for hypothermic alteration in thermoregulation?
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.
A volunteer at the senior center asks the visiting nurse why the senior citizens always seem to be complaining about the temperature. What is the nurse’s best response?
a. Older people have a diminished ability to regulate body temperature because of
active sweat glands.
b. Older people have a diminished ability to regulate body temperature because of
increased circulation.
c. Older people have a diminished ability to regulate body temperature because of
peripheral vasoconstriction.
d. Older people have a diminished ability to regulate body temperature because of
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.
The nurse admitting a patient to the emergency department on a very hot summer day would suspect hyperthermia when the patient demonstrates which assessment finding?
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.
What is the priority nursing action for a patient suspected to be hypothermic?
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.
Which strategies should the nurse include in a community program for senior citizens related to dealing with cold winter temperatures?
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.
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.
What is the most appropriate measure for a nurse to use in assessing core body temperature when there are suspected problems with thermoregulation?
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.
Which similar exemplar should the nurse consider when planning care for a patient with hypothermia?
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.
