Homework Lance
Essentials to Nursing Practice Exam Exam Answers
The nurse is caring for an adult patient who is admitted to the hospital for fever and chills. The nurse repeatedly finds a temperature of 40° C (104° F) in the morning and 38.9° C (102°F) at night. What does the nurse infer about the fever pattern?
Remittent fever
Why is the temperature of deep tissues in older adults lower than that of young adults?
Decreased Immunity
Which factor is associated with a 0.5 to 1° C change in body temperature during a 24-hour period?
Circadian rhythm
The nurse understands that antipyretic drugs reduce body temperature by either increasing heat loss or by interfering with the immune system. Which drugs reduce fever by increasing heat loss?
Acetaminophen
Salicylates
Indomethacin
Ketorolac
The registered nurse is training nursing students and asks the students to convert the patient’s body temperature values from Fahrenheit to Celsius. The patient’s body temperature reads 106° F. What is the Celsius reading of the patient’s temperature? Record your answer to the nearest tenth.
41.1 C
Which heat loss mechanism involves the transfer of heat away by air movement?
Convection
A patient presents with heat stroke. How does the nurse manage the treatment of the patient?
By using oscillating fan
By removing excessive clothing
By using hypothermia blankets
By irrigating the stomach with cool solutions
Which statement is true about body temperature?
It is the difference between the amount of heat produced and the amount of heat lost.
The nurse suspects a patient of having heatstroke. Which signs and symptoms should the nurse look for in the patient?
Nausea
Excessive thirst
Visual disturbances
A registered nurse is asking the nursing student to list the mechanisms that would occur in a patient when the posterior hypothalamus senses that the body temperature is lower than the set point. Which mechanisms listed by the student indicate effective learning?
Muscle shivering
Narrowing of blood vessels
Voluntary muscle contraction
A 55-year-old patient was in a motor vehicle accident and is admitted to a surgical unit after repair of a fractured left arm and left leg. She also has a laceration on her forehead. An intravenous (IV) line is infusing in the right antecubital fossa, and pneumatic compression stockings are on the right lower leg. She is receiving oxygen via a simple face mask. What sites do you instruct the nursing assistant to use for obtaining the patient’s blood pressure and temperature?
Right popliteal and right axillae
Which alteration in the body is prominent when there is a rise in body temperature?
Decreased concentration of iron in the blood.
The nurse is attending to a patient who has a fever. The nurse informs the healthcare provider that the patient is in the plateau stage of fever. Which symptoms would have led the nurse to this conclusion?
Feeling dry
Feeling warm
A woman experiences a rise in body temperature during ovulation. Which hormone is responsible for this?
Progesterone
A 10-year-old child is brought to the hospital with high fever and chills. The nurse records the vital signs and finds that her temperature is 104° F (40° C), blood pressure is 130/85 mm Hg, and pulse rate is 120/min. The fever remains mostly high but is interspersed with periods of normal body temperature. What pattern of fever does the child have?
Intermittent
On examination, the nurse finds that a patient has a temperature of 104° Fahrenheit. What would the temperature be in Celsius? Record your answer using a whole number.
40 C
An older adult with a history of cardiovascular disease is admitted to the emergency department in an unconscious state. Upon assessing the patient’s vitals, the nurse observes a very high body temperature along with increased heart rate and nonreactive pupils. Which intervention would be correct for this patient?
Irrigating the stomach and lower bowel with cool solutions
The nurse is assessing a patient with a respiratory infection. Which signs indicate that the thermostatic set point is raised in the patient?
Chills
Shivering
Piloerection
The nurse in the pediatric intensive care unit is evaluating the vital signs of an infant born to an HIV-positive mother. The infant’s temperature was high in previous readings. The blood reports of the infant are pending. What are the possible sites where temperature can be measured in this patient?
Temporal artery site
Tympanic membrane site
While assessing a patient, the primary health care provider (PHP) finds that the patient is unconscious and the skin is cyanotic. What could be the possible cause?
The patient has been exposed to cold temperatures for a prolonged time.
The nurse notices intense body warmth and sweating lasting for up to 5 minutes in a 50-year-old woman. How does the nurse interpret these symptoms?
The nurse attributes them to menopause.
Which condition is a result of the heat-loss mechanisms of the body becoming overwhelmed?
Heatstroke
A patient has developed a high fever due to a bacterial infection. What are the symptoms the nurse expects to find in the patient?
Confusion
Increased metabolism
Increased heart rate and angina
The nurse is assessing a patient who was brought to the hospital with a body temperature of 41.1° C (106° F). Which signs and symptoms would the nurse likely find in the patient? .
Delirium
Visual disturbances
Increased heart rate
The nurse is giving a tepid sponge bath to a patient. The patient suddenly starts shivering during the bath. How does the nurse manage the shivering of the patient?
Administer meperidine or butorphanol.
Wrap the patient’s extremities.
A patient reports to the nurse increased body temperature in the evening and decreased body temperature in the morning. What does the nurse educate this patient about normal circadian rhythms?
“The highest body temperature occurs at around 4:00 pm.”
“The lowest body temperature occurs between 1:00 am and 4:00 am.”
“A normal body temperature change in a 24-hour period is 0.5° C and 1° C.”
The nurse is attending to a patient with fever. Which nursing interventions are appropriate when caring for this patient?
Provide fluids.
Instruct patient to limit physical activity.
Reduce the external covering of the patient’s body enough so that the heat dissipates but not so much that the patient begins to shiver.
An infant has a fever and is sweating. The pediatrician asks the nurse to measure the patient’s temperature. Which action by the nurse is correct?
Measuring the temperature at the tympanic membrane.
An elderly patient has recently shifted to a residence located at a high altitude and finds it difficult to cope with extreme temperatures. The patient feels that there is a body system problem because the patient experiences more cold than other people do. The nurse explains to the patient that this is a normal response to aging. What is the rationale for this response?
“Aging causes poor vasomotor control.”
“Aging reduces subcutaneous tissue.”
“Aging affects the temperature control mechanism.
The following blood pressures, taken 6 months apart, were from patients screened by the nurse at the assisted-living facility. Which patient should be referred to the healthcare provider for hypertension evaluation?
148/82, 148/78, 134/86
Which patient population would adapt for nonshivering thermogenesis when body metabolism decreases?
Neonates
A patient presents to an emergency room with a high body temperature. Which nursing measures does the nurse implement to reduce the patient’s body temperature?
Switch on a fan.
Apply an ice pack.
Bathe the patient with a cool cloth.
A patient reports a loss of sensation in the fingers and toes after being exposed to cold temperatures. Upon assessment, the nurse observes the injured area becoming white, waxy, and firm to the touch. What condition do these signs and symptoms likely indicate?
Frostbite
A patient has delivered a baby at full term. What does the nurse teach the patient about protecting newborns from environmental temperature?
Teach the importance of adequate clothing.
Emphasize covering the head of the baby with a cap.
Instruct the patient to avoid exposing infants to extreme temperatures.
A healthcare provider instructs the nurse to measure the body temperature of a patient. Which sites does the nurse choose to measure body temperature?
Temporal artery
Pulmonary artery
Tympanic membrane
A 56-year-old patient with diabetes admitted for community-acquired pneumonia has a temperature of 38.2° C (100.8° F) via the temporal artery. Which additional assessment data are needed in planning interventions for the patient’s infection?
Heart rate
Presence of diaphoresis
Respiratory rate
Patient’s normal temperature
The registered nurse is teaching a nursing student about interventions that should be performed for patients with fever to minimize heat production. Which interventions performed by the nursing student reflect effective learning?
Encouraging the patient to increase rest periods.
Advising the patient to avoid turning and ambulating excessively.
The nurse notes that the patient has been experiencing febrile episodes lasting more than 24 hours interrupted by periods of normal body temperature that also last than 24 hours. What does the nurse infer about the patient’s fever pattern?
Relapsing fever
The nurse is learning about different types of fevers. Which statements are true about relapsing fever?
It includes periods of febrile episodes and periods with acceptable temperature values.
Febrile episodes and periods of normothermia are often longer than 24 hours.
A patient has been brought to the emergency department (ED) after falling into a frozen lake. Which body parts should the nurse first assess for the presence of frostbite in the patient?
Earlobes
Fingers
A patient has been hospitalized for the past 48 hours with a fever of unknown origin. His medical record indicates tympanic temperatures of 38.7° C (101.6° F) (4:00 AM), 36.6° C (97.9° F) (8:00 AM), 36.9° C (98.4° F) (noon), 37.6° C (99.6° F) (4:00 PM), and 38.3° C (100.9° F) (8:00 PM). How would you describe this pattern of temperature measurements?
Intermittent-fever pattern
A 10-year-old child is brought to the hospital with high fever and chills. The nurse records the vital signs and finds that her temperature is 104° F (40° C), blood pressure is 130/85 mm Hg, and pulse rate is 120/min. The fever remains mostly high but is interspersed with periods of normal body temperature. What measures should the nurse adopt to reduce fever in the patient?
Administer antipyretics as ordered.
Use cooling blankets.
Administer meperidine as ordered.
Which statements accurately describe body temperature?
Pulmonary artery catheters measure core temperatures.
Temperature values are affected by the temperature measurement site.
A patient reports fever and chills. The nurse reviews the case sheet and finds that the patient has a history of otitis media and is taking medication. Which temperature measurement site would the nurse avoid for this patient?
Tympanic membrane
Which site would the nurse choose to document continuous core temperature while the patient is in the intensive care unit?
Urinary bladder
The registered nurse is teaching a nursing student about the advantages and disadvantages of selecting temperature measurement sites. Which statement by the nursing student indicates the need for further teaching?
“The tympanic membrane site is easily accessible without changing position to measure temperature.”
The nurse is conducting a class on different temperature measurement sites. In which patients should the tympanic membrane be used as a site for temperature measurement?
In patients who do not mind the removal of their hearing aids.
In patients complaining of tachypnea.
A 10-year-old child is brought to the hospital with high fever and chills. The nurse records the vital signs and finds that the temperature is 104° F, blood pressure is 130/85 mm Hg, and pulse rate is 120 beats/minute. The fever remains mostly high but is interspersed with periods of normal body temperature. What factors affect the body temperature of a patient?
Age
Stress
Hormonal Changes
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