The nurse is listing consequences of malignant hyperthermia.
Which consequences should be included? (select all that apply)
A. Disseminated intravascular coagulation
A. Disseminated intravascular coagulation
B. Renal failure
B. Renal failure
C. Cardiac dysrhythmias
C. Cardiac dysrhythmias
E. Pulmonary edema
D. Gastroenteritis
E. Pulmonary edema
Which type of body temperature changes in response to the
environment?
A. core
C. Surface
B. metabolic
C. surface
D. physiologic
B. Evaporation
The nurse observes a mother stroking her child's arms and legs
with a cool, damp washcloth. Which method of heat transfer is the
Rationale: Heat can be transferred between places or objects.
mother using to reduce the fever?
Evaporation is the conversion of water to vapor, which is what
A. Radiation
occurs when the mother applies cool water to the child's limbs.
B. Evaporation
Radiation is the release of heat through no physical contact. Con-
C. Conduction
duction is the release of heat through physical contact. Metabolism
D. Metabolism
is not a method of heat transfer
An older adult client asks the nurse, "Why is my body temperatureD. "Body temperature in an older adult is not a reliable indicator of
t h e se riousness of an illness."
only 99°F if I have this serious infection?" Which is the nurse' s b e t
response? Rationale: Body temperature may not be a valid indication of
A. "Your body temperature fluctuates significantly, so a true tem-serious illness in an older adult. The older adult may have an
perature is difficult to obtain." infection and exhibit only a slight temperature elevation. Other
B. "I will to take your temperature rectally, since it is the only symptoms, such as confusion and restlessness, may be presen
reliable route in somebody your age." These require follow-up to determine whether an underlying dis
C. "The true temperature will not register because you are a mouth ease process is present. There is no evidence to support that
breather." the client is a mouth breather. Rectal temperatures in older adult
D. "Body temperature in an older adult is not a reliable indicator of clients may be contraindicated if hemorrhoids are present. Body
the seriousness of an illness."
temperature in an older adult does not fluctuate significantly.
The nurse is assessing a client who fell into a cold lake. Which B. Cold hands
assessment finding indicates that the client's body is attemptingD. shivers
to regulate its temperature? (Select all that apply.)
A. Sweating Rationale: When the skin is chilled, the body attempts to regulat
B. Cold hands temperature by vasoconstriction of blood vessels. This could be
C. Thirst why the client's hands are cold. The body also shivers to increas
D. Shivering heat production. The body does not regulate temperature through
E. Sleepiness sleep, thirst, or by sweating.
B. Heat stroke
Rationale: The nurse should suspect heat stroke, which can occu
during hot weather and high humidity and results in dysfunc-
tio n of the brain's thermoregulation center. Signs and symptoms
On a hot, humid day, a client presents with a body temperature o ff heat-related injuries include paleness, dizziness, nausea a
40.9°C (105.6°F), dry and flush skin, vomiting, low blood pressu r e,
vomiting, fatigue, low blood pressure, muscle cramps, and fain
and muscle cramps. Which type of injury should the nurse suspect
Late signs include irritability, confusion, stupor, and coma. Hy
based on the manifestations?
A. Malignant hyperthermia pothermia is a core body temperature below 35°C (95°F), and
B. Heat stroke is classified as mild, 32dash- 35°C (89.6dash- 95°F); m
C. Hypothermia 28dash- 32°C (82.4dash- 89.6°F), or severe, below 28°C
82.4°F). The usual range of core body temperature is called nor-
D. Normothermia
mothermia. The normal range for adults is between 36°C and
38.5°C (96.8°F and 101.3°F). Malignant hyperthermia is a poten
tially fatal, inherited disorder that results from the body's reac
to volatile inhalation of anesthetic gases and succinylcholine, a
depolarizing neuromuscular blocker.
The nurse is preparing to use the tympanic membrane to measure C. pull the pinna back and up
the temperature of a 4-year-old child. Which approach should the
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