lOM oA R c P S D| 301 38 04
Test-bank for Concepts for Nursing
Practice 3rd Edition= Chapter 1-
update 2024 -2025 Complete Guide A+
Concept 1: Thermoregulation
Concepts for Nursing Practice, 3rd Edition
MULTIPLE CHOICE
1. 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.
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 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. N
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.
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 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.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
4. 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.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
5. 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 paN rk
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.
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.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
7. 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
, lOM oA R c P S D| 301 38 04
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.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
8. Which similar exemplar should the nurse consider when planning care for a patient with
hypothermia?
a. Heat exhaustion N
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.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
Concept 01: Development
MULTIPLE CHOICE
1. The nurse manager of a pediatric clinic could confirm that the new nurse recognized the
purpose of the HEADSS Adolescent Risk Profile when the new nurse responds that it is
used to assess for needs related to
a. anticipatory guidance.
b. low-risk adolescents.
c. physical development.
d. sexual development.
ANS: A
The HEADSS Adolescent Risk Profile is a psychosocial assessment screening tool which
assesses home, education, activities, drugs, sex, and suicide for the purpose of identifying
high-risk adolescents and the need for anticipatory guidance. It is used to identify high-risk,
not low-risk, adolescents. Physical development is assessed with anthropometric data.
Sexual development is assessed using physical examination.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
2. The nurse preparing a teaching plan for a preschooler knows that, according to Piaget, the
expected stage of development for a preschooler is
a. concrete operational.
b. formal operational. N
c. preoperational.
d. sensorimotor.
ANS: C
The expected stage of development for a preschooler (3–4 years old) is pre-operational.
Concrete operational describes the thinking of a school-age child (7–11 years old). Formal
operational describes the thinking of an individual after about 11 years of age. Sensorimotor
describes the earliest pattern of thinking from birth to 2 years old.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
Test-bank for Concepts for Nursing
Practice 3rd Edition= Chapter 1-
update 2024 -2025 Complete Guide A+
Concept 1: Thermoregulation
Concepts for Nursing Practice, 3rd Edition
MULTIPLE CHOICE
1. 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.
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 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. N
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.
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 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.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
4. 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.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
5. 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 paN rk
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.
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.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
7. 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
, lOM oA R c P S D| 301 38 04
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.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
8. Which similar exemplar should the nurse consider when planning care for a patient with
hypothermia?
a. Heat exhaustion N
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.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
Concept 01: Development
MULTIPLE CHOICE
1. The nurse manager of a pediatric clinic could confirm that the new nurse recognized the
purpose of the HEADSS Adolescent Risk Profile when the new nurse responds that it is
used to assess for needs related to
a. anticipatory guidance.
b. low-risk adolescents.
c. physical development.
d. sexual development.
ANS: A
The HEADSS Adolescent Risk Profile is a psychosocial assessment screening tool which
assesses home, education, activities, drugs, sex, and suicide for the purpose of identifying
high-risk adolescents and the need for anticipatory guidance. It is used to identify high-risk,
not low-risk, adolescents. Physical development is assessed with anthropometric data.
Sexual development is assessed using physical examination.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
2. The nurse preparing a teaching plan for a preschooler knows that, according to Piaget, the
expected stage of development for a preschooler is
a. concrete operational.
b. formal operational. N
c. preoperational.
d. sensorimotor.
ANS: C
The expected stage of development for a preschooler (3–4 years old) is pre-operational.
Concrete operational describes the thinking of a school-age child (7–11 years old). Formal
operational describes the thinking of an individual after about 11 years of age. Sensorimotor
describes the earliest pattern of thinking from birth to 2 years old.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
