A homeless person is brought to the emergency department after prolonged exposure to cold weather. The nurse would assess the patient for what manifestations of hypothermia?

A homeless person is brought to the emergency department after prolonged exposure to cold weather. The nurse would assess the patient for what manifestations of hypothermia?

Answer: Stupor may occur with hypothermia because of slowed cerebral metabolic processes.

What clinical indicator will the nurse most likely identify when assessing a patient with pyrexia?

What clinical indicator will the nurse most likely identify when assessing a patient with pyrexia?

Answer: The pulse rate increases to meet increased tissue demands for oxygen in the febrile state.

A patient with hypothermia is brought to the emergency department. The nurse should explain which most likely treatment to the family members?

A patient with hypothermia is brought to the emergency department. The nurse should explain which most likely treatment to the family members?

Answer: Core rewarming with heated oxygen and administration of warmed oral or intravenous fluids is the preferred method of treatment.

A child is about to be admitted to the pediatric intensive care unit (PICU) after surgery for removal of a tumor in the hypothalamic region of the brain. The nurse manager should intervene immediately when observing the child's nurse perform which action?

A child is about to be admitted to the pediatric intensive care unit (PICU) after surgery for removal of a tumor in the hypothalamic region of the brain. The nurse manager should intervene immediately when observing the child's nurse perform which action?

Answer: It is not safe to put the bed in the Trendelenburg position, because raising the foot increases blood flow to the brain, thereby increasing intracranial pressure. Temperature elevations may occur after a craniotomy because of stimulation of the hypothalamus.

The nurse identifies which priority nursing invention for a patient with hyperthermia?

The nurse identifies which priority nursing invention for a patient with hyperthermia?

Answer: Removing excess clothing. Seizures may occur because of a high body temperature, so decreasing heat absorption through clothing is the highest priority.

The nurse admitting a patient to the emergency room on a cold winter night would suspect hypothermia when the patient demonstrates

The nurse admitting a patient to the emergency room on a cold winter night would suspect hypothermia when the patient demonstrates

Answer: slow capillary refill.

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

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

Answer: Prematurity, frost bite, environmental exposure, and brain injury are considered exemplars of hypothermia.

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?

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?

Answer: Physical agility is not a risk factor for impaired thermoregulation. Impaired cognition, occupational exposure, and temperature extremes are risk factors.

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

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

Answer: Shopping indoors where there is protection from the elements and temperature control is one strategy to avoid cold temperatures.

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

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

Answer: 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.

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

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

Answer: red, sweaty skin. Vasodilation occurs causing the skin to appear flushed and warm to touch. With hyperthermia, respiratory rate and heart rate increases.

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 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

Answer: Slower metabolic rates.

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

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

Answer: Low birth weight and poorly nourished infants (particularly premature infants) and children are at greatest risk for hypothermia.