Chapter 29: Vital Signs
ra ra ra
MULTIPLE CHOICE ra
1. A hospital client has a head injury and damages the hypothalamus. Which vital sign will
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t he nursing attendant monitor most closely? a. Pulse
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b. Respirations
c. Temperature
d. Blood pressure ra
ACCURATE ar
ANSWER:-C
Disease or trauma to the hypothalamus or the spinal cord, which carries hypothalamic mess
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ages, causes serious alterations in temperature control. The hypothalamus does not control pu
ra ra ra ra ra ra ra ra ra ra ar ra
lse, respirations, or blood pressure.
ra ra ra ra
DIF:Understand (comprehension) ra
OBJ:Select nursing measures that promote heat loss and heat conservation.
ra ra ra ra ra ra ra ra ra ar
TOP:Assessment MSC: Physiological Adaptation ra ra
2. A hospital client presents with heatstroke. The nursing attendant uses cool packs, cool
ra ra ra ra ra ra ra ra ra ra ra ra
ing blanket, and a fan. Which technique is the nursing attendant using when the fan pro
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar
duces heat loss? a. Radiation ra ra
b. Conduction
c. Convection
d. Evaporation
ACCURATE ANSWER:-C ra
Convection is the transfer of heat away from the body by air movement. Conduction is the tra
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
nsfer of heat from one object to another with direct contact. Radiation is the transfer of heat fro
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar
m the surface of one object to the surface of another without direct contact between the two.
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
Evaporation is the transfer of heat energy when a liquid is changed to a gas.
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
DIF:Understand (comprehension) ra
OBJ:Select nursing measures that promote heat loss and heat conservation.
ra ra ra ra ra ra ra ra ra ar
TOP:Implementation MSC: Basic Care and Comfort ra ra ra
3. The hospital client has a temperature of 105.
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The nursing attendant is attempting to lo
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wer temperature by providing tepid sponge baths and placing cool compresses in strate
ra ra ra ra ra ra ra ra ra ra ra ra
gic b ar
ody locations. Which technique is the nursing attendant using to lower the hospital clie
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nt ’s temperature?
ra ar
a. Radiation
b. Conduction
c. Convection
d. Evaporation
ACCURATE ANSWER:-B ra
, Applying an ice pack or bathing a hospital client with a cool cloth increases conductive heat lo
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar
ss because of the direct contact. Radiation is the transfer of heat from the surface of one objec
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
t to the surface of another without direct contact between the two. Evaporation is the transfe
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
r of heat energy when a liquid is changed to a gas. Convection is the transfer of heat away fro
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
m the body by air movement.
ra ra ra ra ra
DIF:Understand (comprehension) ra
OBJ:Analyze a hospital client ’s body t ra ra ra ra ra ar
emperature. TOP:Implementation ra MSC: Basic Care and Comfort ra ra ra
4. A nursing attendant is focusing on temperature regulation of newborns and infants. Wh
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ic h action will the nursing attendant take? a. Apply just a diaper.
ar ra ra ra ra ra ra ra ra
b. Double the clothing. ra ra
c. Place a cap on their heads. ra ra ra ra ra
d. Increase room temperature to 90 degrees. ra ra ra ra ra
ACCURATE ANSWER:-C ra
A newborn loses up to 30% of body heat through the head and therefore needs to wear a cap t
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
o prevent heat loss. Temperature control mechanisms in newborns are immature and respond
ra ra ra ra ra ra ra ra ra ra ra ra ar
drastically to changes in the environment; do not increase the room temperature to 90 degrees.
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar
Take extra care to protect newborns from environmental temperatures. Provide adequate clo
ra ra ra ra ra ra ra ra ra ra ra
thing; do not double the clothing or apply just a diaper.
ra ra ra ra ra ra ra ra ra ra
DIF:Apply (application) ra
OBJ:Select nursing measures that promote heat loss and heat conservation.
ra ra ra ra ra ra ra ra ra
TOP:Implementation MSC: Health Promotion and Maintenance ra ra ra
5. The nursing attendant is working the night shift on a surgical unit and is making 4:00 A
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
M rounds. The nursing attendant notices that the hospital client ’s temperature is
ar ra ra ra ra ra ra ra ra ra ra ra ra
(3 whereas at 4:00 PM the preceding day, it was
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ra
What should the nur
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sing attendant do? ra ra
a. Call the health care provider immediately to report a possible infection.
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b. Administer medication to lower the temperature further. ra ra ra ra ra ra
c. Provide another blanket to conserve body temperature. ra ra ra ra ra ra
d. Realize that this is a normal temperature variation. ra ra ra ra ra ra ra
ACCURATE ANSWER:-D ra
Body temperature normally changes
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to to during a 24- ra ra ra
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ra ra ra
hour period and is usually lowest between 1:00 and 4:00 AM, with a maximum temperature at
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4:00 PM, making this variation normal for the time of day. Unless the hospital client reports b
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
eing cold, there is no physiological need for providing an extra blanket or medication to lower
ra ra ra ar ra ra ra ra ra ra ra ra ra ra ra ra
the body temperature further. There is also no need to call a health care provider to report a n
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
ormal temperature variation. ra ra
DIF:Apply (application) ra
OBJ:Select nursing measures that promote heat loss and heat conservation. TO
ra ra ra ra ra ra ra ra ra ra
P:Implementation MSC:
Health Promotion and Maintenance ar ra ra
,6.
ra
The nursing attendant is caring for a hospital client who has a temperature reading of 10
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0.4 The hospital client ’s last two temperature readings were
ra ra and 96.8 ra ra ra ra ra ra ra ra
ra
ra ar
ra Which action will the nursing attendant take?
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a. Wait 30 minutes and recheck the hospital client ’s temperature.
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b. Assume that the hospital client has an infection and order blood cultures.
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c. Encourage the hospital client to move around to increase muscular activity.
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d. Be aware that temperatures this high are harmful and affect hospital client safety.
ra ra ra ra ra ra ra ra ra ra ra ra
ACCURATE ANSWER:-A ra
Waiting 30 minutes and rechecking the hospital client ’s temperature would be the most ap
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
propriate action in this case. A fever is usually not harmful if it stays below
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
ra ra
and a single temperature reading does not always indicate a fever. In addition to physical sig
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
ns and symptoms of infection, a fever determination is based on several temperature reading
ra ra ra ra ra ra ra ra ra ra ra ra ra
s at different times of the day compared with the usual value for that person at that time. Nu
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
rsing attendant s should base actions on knowledge, not on assumptions. Encouraging the h
ra ra ra ra ra ra ra ra ra ra ra ra ra
ospital client to increase muscular activity will cause heat production to increase up to 50 ti
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
mes normal. The temperature has decreased and a symptom of infection would be an increase
ra ra ra ra ra ra ra ra ar ra ra ra ra ra
in temperature.
ra ra
DIF:Apply (application) ra
OBJ:Select nursing measures that promote heat loss and heat conservation.
ra ra ra ra ra ra ra ra ra ar
TOP:Implementation MSC: Reduction of Risk Potential ra ra ra
7.
A hospital client is experiencing pyrexia. Which piece of equipment will the nursin
ra ra ra ra ra ra ra ra ra ra ra ra
g a ttendant obtain to monitor this condition? a. Stethoscope
ar ra ra ra ra ra
b. Thermometer
c. Blood pressure cuff ra ra
d. Sphygmomanometer
ACCURATE ANSWER:-B ra
Pyrexia, or fever, occurs because heat loss mechanisms are unable to keep pace with excess he
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
at production, resulting in an abnormal rise in body temperature; therefore, a thermometer is n
ra ra ra ra ra ra ra ra ra ra ra ra ra ar
eeded. A stethoscope is not used to take a temperature but can be used for apical pulse and bl
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
ood pressure. A pulse oximeter is used to determine oxygen content in the blood. A sphygmo
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
manometer and blood pressure cuff is used to determine blood pressure and will be used for b
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
lood pressure problems. ra ra
DIF:Apply (application) ra
OBJ:Summarize physiological changes associated with fever. ra ra ra ra ra
TOP:Assessment ar
MSC: Health Promotion and Maintenance
ra ra ra ra
8. The nursing attendant is caring for a hospital client who has an elevated temperature.
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
Which principle will the nursing attendant consider when planning care for this hosp
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it al client ? ar ra
a. Hyperthermia and fever are the same thing. ra ra ra ra ra ra
b. Hyperthermia is an upward shift in the set point. ra ra ra ra ra ra ra ra
c. Hyperthermia occurs when the body cannot reduce heat production. ra ra ra ra ra ra ra ra
, d. Hyperthermia results from a reduction in thermoregulatory mechanisms. ra ra ra ra ra ra ra
ACCURATE ANSWER:-C ra
An elevated body temperature related to the inability of the body to promote heat loss or
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra r
areduce heat production is hyperthermia. Whereas fever is an upward shift in the set point
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
, hyperthermia results from an overload of the thermoregulatory mechanisms of the body.
ar ra ra ra ra ra ra ra ra ra ra ra
DIF:Understand (comprehension) ra
OBJ:Summarize physiological changes associated with fever. ra ra ra ra ra
TOP:Planning ar
MSC: Physiological Adaptation ra ra
9. The hospital client with heart failure is restless with a temperature of
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Which action will the nursing attendant take? a.
ra a
r ra ra ra ra ra ra
Place the hospital client on oxygen.
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b. Encourage the hospital client to cough. ra ra ra ra ra
c. Restrict the hospital client ’s fluid intake. ra ra ra ra ra ra
d. Increase the hospital client ’s metabolic rate. ra ra ra ra ra ra
ACCURATE ANSWER:-A ra
Interventions during a fever include oxygen therapy. During a fever, cellular metabolism incre
ra ra ra ra ra ra ra ra ra ra ra ra
ases, and oxygen consumption rises. Myocardial hypoxia produces angina. Cerebral hypoxia
ra ra ra ra ra ra ra ra ra ra ra
produces confusion. Dehydration is a serious problem through increased respiration and diap
ra ra ra ra ra ra ra ra ra ra ra
horesis. The hospital client is at risk for fluid volume deficit. Fluids should not be restricted, e
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
ven though the hospital client has heart failure; the hospital client needs fluids at this time du
ra ra ra ra ra ra ra ra ra ra ra ra ra ar ra ra
e to the fever. Increasing the metabolic rate further would not be advisable.
ra ra ra ra ra ra ra ra ra ra ra ra
Coughing will increase muscular activity, which will increase fever.
ra ra ra ra ra ra ra ra
DIF:Apply (application) ra
OBJ:Summarize physiological changes associated with fever. ra ra ra ra ra
TOP:Implementatio n MSC: Reduction of Risk Potential ar ra ra ra ra
10. The hospital client requires temperatures to be taken every 2 hours. Which tas
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k will be the responsibility of an RN?
ar ra ra ra ra ra ra
a. Using appropriate route and device ra ra ra ra
b. Assessing changes in body temperature ra ra ra ra
c. Being aware of the usual values for the hospital client ra ra ra ra ra ra ra ra ra
d. Obtaining temperature measurement at ordered frequency ra ra ra ra ra
ACCURATE ANSWER:-B ra
The nursing attendant is responsible for assessing changes in body temperature. The nursing a
ra ra ra ra ra ra ra ra ra ra ra ra ar
ssistive personnel can use the appropriate route and device to measure temperature, obtain te
ra ra ra ra ra ra ra ra ra ra ra ra ar
mperature measurement at ordered frequency, and be aware of the usual values for the hospit
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
al client . ra ra
DIF:Apply (application) ra
OBJ:Determine when it is appropriate to delegate of vital sign measurements to nursing assistivera ra ra ra ra ra ra ra ra ra ra ra ra ar
personnel. TOP:Implementation MSC: Management of Care ra ra
11. The hospital client requires routine temperature assessment but is confused, easily agitated,
ra ra ra ra ra ra ra ra ra ra ra ra
and has a history of seizures. Which route will the nursing attendant use to obtain the hospi
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
t al client ’s temperature? a. Oral
ar ra ra
b. Rectal
ra ra ra
MULTIPLE CHOICE ra
1. A hospital client has a head injury and damages the hypothalamus. Which vital sign will
ra ra ra ra ra ra ra ra ra ra ra ra ra ra a
t he nursing attendant monitor most closely? a. Pulse
r ra ra ra ra ra
b. Respirations
c. Temperature
d. Blood pressure ra
ACCURATE ar
ANSWER:-C
Disease or trauma to the hypothalamus or the spinal cord, which carries hypothalamic mess
ra ra ra ra ra ra ra ra ra ra ra ra ra
ages, causes serious alterations in temperature control. The hypothalamus does not control pu
ra ra ra ra ra ra ra ra ra ra ar ra
lse, respirations, or blood pressure.
ra ra ra ra
DIF:Understand (comprehension) ra
OBJ:Select nursing measures that promote heat loss and heat conservation.
ra ra ra ra ra ra ra ra ra ar
TOP:Assessment MSC: Physiological Adaptation ra ra
2. A hospital client presents with heatstroke. The nursing attendant uses cool packs, cool
ra ra ra ra ra ra ra ra ra ra ra ra
ing blanket, and a fan. Which technique is the nursing attendant using when the fan pro
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar
duces heat loss? a. Radiation ra ra
b. Conduction
c. Convection
d. Evaporation
ACCURATE ANSWER:-C ra
Convection is the transfer of heat away from the body by air movement. Conduction is the tra
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
nsfer of heat from one object to another with direct contact. Radiation is the transfer of heat fro
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar
m the surface of one object to the surface of another without direct contact between the two.
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
Evaporation is the transfer of heat energy when a liquid is changed to a gas.
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
DIF:Understand (comprehension) ra
OBJ:Select nursing measures that promote heat loss and heat conservation.
ra ra ra ra ra ra ra ra ra ar
TOP:Implementation MSC: Basic Care and Comfort ra ra ra
3. The hospital client has a temperature of 105.
ra ra ra ra ra ra ra
The nursing attendant is attempting to lo
ra ra ra ra ra ra ra
wer temperature by providing tepid sponge baths and placing cool compresses in strate
ra ra ra ra ra ra ra ra ra ra ra ra
gic b ar
ody locations. Which technique is the nursing attendant using to lower the hospital clie
ra ra ra ra ra ra ra ra ra ra ra ra ra
nt ’s temperature?
ra ar
a. Radiation
b. Conduction
c. Convection
d. Evaporation
ACCURATE ANSWER:-B ra
, Applying an ice pack or bathing a hospital client with a cool cloth increases conductive heat lo
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar
ss because of the direct contact. Radiation is the transfer of heat from the surface of one objec
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
t to the surface of another without direct contact between the two. Evaporation is the transfe
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
r of heat energy when a liquid is changed to a gas. Convection is the transfer of heat away fro
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
m the body by air movement.
ra ra ra ra ra
DIF:Understand (comprehension) ra
OBJ:Analyze a hospital client ’s body t ra ra ra ra ra ar
emperature. TOP:Implementation ra MSC: Basic Care and Comfort ra ra ra
4. A nursing attendant is focusing on temperature regulation of newborns and infants. Wh
ra ra ra ra ra ra ra ra ra ra ra ra
ic h action will the nursing attendant take? a. Apply just a diaper.
ar ra ra ra ra ra ra ra ra
b. Double the clothing. ra ra
c. Place a cap on their heads. ra ra ra ra ra
d. Increase room temperature to 90 degrees. ra ra ra ra ra
ACCURATE ANSWER:-C ra
A newborn loses up to 30% of body heat through the head and therefore needs to wear a cap t
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
o prevent heat loss. Temperature control mechanisms in newborns are immature and respond
ra ra ra ra ra ra ra ra ra ra ra ra ar
drastically to changes in the environment; do not increase the room temperature to 90 degrees.
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar
Take extra care to protect newborns from environmental temperatures. Provide adequate clo
ra ra ra ra ra ra ra ra ra ra ra
thing; do not double the clothing or apply just a diaper.
ra ra ra ra ra ra ra ra ra ra
DIF:Apply (application) ra
OBJ:Select nursing measures that promote heat loss and heat conservation.
ra ra ra ra ra ra ra ra ra
TOP:Implementation MSC: Health Promotion and Maintenance ra ra ra
5. The nursing attendant is working the night shift on a surgical unit and is making 4:00 A
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
M rounds. The nursing attendant notices that the hospital client ’s temperature is
ar ra ra ra ra ra ra ra ra ra ra ra ra
(3 whereas at 4:00 PM the preceding day, it was
ra ra ra ra ra ra ra ra ra ra ra
ra
What should the nur
ra ra ra ra
sing attendant do? ra ra
a. Call the health care provider immediately to report a possible infection.
ra ra ra ra ra ra ra ra ra ra
b. Administer medication to lower the temperature further. ra ra ra ra ra ra
c. Provide another blanket to conserve body temperature. ra ra ra ra ra ra
d. Realize that this is a normal temperature variation. ra ra ra ra ra ra ra
ACCURATE ANSWER:-D ra
Body temperature normally changes
ra
to to during a 24- ra ra ra
ra ra ra ra ra
ra ra ra
hour period and is usually lowest between 1:00 and 4:00 AM, with a maximum temperature at
ra ra ra ar ra ra ra ra ra ra ra ra ra ra ra ra
4:00 PM, making this variation normal for the time of day. Unless the hospital client reports b
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
eing cold, there is no physiological need for providing an extra blanket or medication to lower
ra ra ra ar ra ra ra ra ra ra ra ra ra ra ra ra
the body temperature further. There is also no need to call a health care provider to report a n
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
ormal temperature variation. ra ra
DIF:Apply (application) ra
OBJ:Select nursing measures that promote heat loss and heat conservation. TO
ra ra ra ra ra ra ra ra ra ra
P:Implementation MSC:
Health Promotion and Maintenance ar ra ra
,6.
ra
The nursing attendant is caring for a hospital client who has a temperature reading of 10
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
0.4 The hospital client ’s last two temperature readings were
ra ra and 96.8 ra ra ra ra ra ra ra ra
ra
ra ar
ra Which action will the nursing attendant take?
ra ra ra ra ra ra ra
a. Wait 30 minutes and recheck the hospital client ’s temperature.
ra ra ra ra ra ra ra ra ra
b. Assume that the hospital client has an infection and order blood cultures.
ra ra ra ra ra ra ra ra ra ra ra
c. Encourage the hospital client to move around to increase muscular activity.
ra ra ra ra ra ra ra ra ra ra
d. Be aware that temperatures this high are harmful and affect hospital client safety.
ra ra ra ra ra ra ra ra ra ra ra ra
ACCURATE ANSWER:-A ra
Waiting 30 minutes and rechecking the hospital client ’s temperature would be the most ap
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
propriate action in this case. A fever is usually not harmful if it stays below
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
ra ra
and a single temperature reading does not always indicate a fever. In addition to physical sig
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
ns and symptoms of infection, a fever determination is based on several temperature reading
ra ra ra ra ra ra ra ra ra ra ra ra ra
s at different times of the day compared with the usual value for that person at that time. Nu
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
rsing attendant s should base actions on knowledge, not on assumptions. Encouraging the h
ra ra ra ra ra ra ra ra ra ra ra ra ra
ospital client to increase muscular activity will cause heat production to increase up to 50 ti
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
mes normal. The temperature has decreased and a symptom of infection would be an increase
ra ra ra ra ra ra ra ra ar ra ra ra ra ra
in temperature.
ra ra
DIF:Apply (application) ra
OBJ:Select nursing measures that promote heat loss and heat conservation.
ra ra ra ra ra ra ra ra ra ar
TOP:Implementation MSC: Reduction of Risk Potential ra ra ra
7.
A hospital client is experiencing pyrexia. Which piece of equipment will the nursin
ra ra ra ra ra ra ra ra ra ra ra ra
g a ttendant obtain to monitor this condition? a. Stethoscope
ar ra ra ra ra ra
b. Thermometer
c. Blood pressure cuff ra ra
d. Sphygmomanometer
ACCURATE ANSWER:-B ra
Pyrexia, or fever, occurs because heat loss mechanisms are unable to keep pace with excess he
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
at production, resulting in an abnormal rise in body temperature; therefore, a thermometer is n
ra ra ra ra ra ra ra ra ra ra ra ra ra ar
eeded. A stethoscope is not used to take a temperature but can be used for apical pulse and bl
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
ood pressure. A pulse oximeter is used to determine oxygen content in the blood. A sphygmo
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
manometer and blood pressure cuff is used to determine blood pressure and will be used for b
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
lood pressure problems. ra ra
DIF:Apply (application) ra
OBJ:Summarize physiological changes associated with fever. ra ra ra ra ra
TOP:Assessment ar
MSC: Health Promotion and Maintenance
ra ra ra ra
8. The nursing attendant is caring for a hospital client who has an elevated temperature.
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
Which principle will the nursing attendant consider when planning care for this hosp
ra ra ra ra ra ra ra ra ra ra ra ra
it al client ? ar ra
a. Hyperthermia and fever are the same thing. ra ra ra ra ra ra
b. Hyperthermia is an upward shift in the set point. ra ra ra ra ra ra ra ra
c. Hyperthermia occurs when the body cannot reduce heat production. ra ra ra ra ra ra ra ra
, d. Hyperthermia results from a reduction in thermoregulatory mechanisms. ra ra ra ra ra ra ra
ACCURATE ANSWER:-C ra
An elevated body temperature related to the inability of the body to promote heat loss or
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra r
areduce heat production is hyperthermia. Whereas fever is an upward shift in the set point
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
, hyperthermia results from an overload of the thermoregulatory mechanisms of the body.
ar ra ra ra ra ra ra ra ra ra ra ra
DIF:Understand (comprehension) ra
OBJ:Summarize physiological changes associated with fever. ra ra ra ra ra
TOP:Planning ar
MSC: Physiological Adaptation ra ra
9. The hospital client with heart failure is restless with a temperature of
ra ra ra ra ra ra ra ra ra ra ra ra
Which action will the nursing attendant take? a.
ra a
r ra ra ra ra ra ra
Place the hospital client on oxygen.
ra ra ra ra ra
b. Encourage the hospital client to cough. ra ra ra ra ra
c. Restrict the hospital client ’s fluid intake. ra ra ra ra ra ra
d. Increase the hospital client ’s metabolic rate. ra ra ra ra ra ra
ACCURATE ANSWER:-A ra
Interventions during a fever include oxygen therapy. During a fever, cellular metabolism incre
ra ra ra ra ra ra ra ra ra ra ra ra
ases, and oxygen consumption rises. Myocardial hypoxia produces angina. Cerebral hypoxia
ra ra ra ra ra ra ra ra ra ra ra
produces confusion. Dehydration is a serious problem through increased respiration and diap
ra ra ra ra ra ra ra ra ra ra ra
horesis. The hospital client is at risk for fluid volume deficit. Fluids should not be restricted, e
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
ven though the hospital client has heart failure; the hospital client needs fluids at this time du
ra ra ra ra ra ra ra ra ra ra ra ra ra ar ra ra
e to the fever. Increasing the metabolic rate further would not be advisable.
ra ra ra ra ra ra ra ra ra ra ra ra
Coughing will increase muscular activity, which will increase fever.
ra ra ra ra ra ra ra ra
DIF:Apply (application) ra
OBJ:Summarize physiological changes associated with fever. ra ra ra ra ra
TOP:Implementatio n MSC: Reduction of Risk Potential ar ra ra ra ra
10. The hospital client requires temperatures to be taken every 2 hours. Which tas
ra ra ra ra ra ra ra ra ra ra ra ra
k will be the responsibility of an RN?
ar ra ra ra ra ra ra
a. Using appropriate route and device ra ra ra ra
b. Assessing changes in body temperature ra ra ra ra
c. Being aware of the usual values for the hospital client ra ra ra ra ra ra ra ra ra
d. Obtaining temperature measurement at ordered frequency ra ra ra ra ra
ACCURATE ANSWER:-B ra
The nursing attendant is responsible for assessing changes in body temperature. The nursing a
ra ra ra ra ra ra ra ra ra ra ra ra ar
ssistive personnel can use the appropriate route and device to measure temperature, obtain te
ra ra ra ra ra ra ra ra ra ra ra ra ar
mperature measurement at ordered frequency, and be aware of the usual values for the hospit
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
al client . ra ra
DIF:Apply (application) ra
OBJ:Determine when it is appropriate to delegate of vital sign measurements to nursing assistivera ra ra ra ra ra ra ra ra ra ra ra ra ar
personnel. TOP:Implementation MSC: Management of Care ra ra
11. The hospital client requires routine temperature assessment but is confused, easily agitated,
ra ra ra ra ra ra ra ra ra ra ra ra
and has a history of seizures. Which route will the nursing attendant use to obtain the hospi
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
t al client ’s temperature? a. Oral
ar ra ra
b. Rectal
