HCC EXAM 1 (TISSUE INTEGRITY AND
THERMOREGULATION) QUESTIONS
WITH COMPLETE SOLUTIONS
A nurse is caring for a preterm newborn born at 29 weeks' gestation. Which nursing
diagnosis would have the highest priority? - Answer Ineffective thermoregulation related
to decreased amount of subcutaneous fat.
Hypothermia may occur as a result of... - Answer Open body wounds.
A homeless client presents to the ED. Upon assessment, the client is experiencing
hypothermia. The nurse will plan to complete which priority intervention during the
rewarming process? - Answer Attach a cardiac monitor.
A nurse is assessing a full-term neonate and discovers a heart rate of 100 beats/minute
and an axillary temperature of 97.3°F (36.3°C). What action should the nurse take? -
Answer Place a cap on the neonate's head, and offer the neonate to the mother for
skin-to-skin.
A nurse is admitting a pregnant woman with sickle cell anemia to the emergency
department. Which findings would lead the nurse to suspect the client is in crisis? Select
all that apply. - Answer fever
joint pain
fatigue
A client in the operating room goes into malignant hyperthermia due to an abnormal
reaction to the anesthetic. The nurse knows that the area of the brain that regulates
body temperature is what? - Answer Hypothalamus
A client has a fever that was induced by damage to the hypothalamus due to inter-
cranial bleeding. The nurse plans care for which type of fever? - Answer Neurogenic
The nurse is recording vital signs in the client diagnosed with complications of anorexia
nervosa. Which findings are consistent with the condition? Select all that apply. -
Answer orthostatic hypotension
, hypothermia
weak pulse
A woman who gave birth 10 hours ago is ambulating to the bathroom and calls for
assistance with perineal care. When the nurse touches her skin, the nurse notices that
she is excessively warm. After reinforcing the woman's self-care, the nurse encourages
increased oral intake. Why was this the appropriate instruction to give to this client? -
Answer Increased intake will rehydrate the client and decrease her skin temperature.
A woman gave birth vaginally approximately 12 hours ago, and her temperature is now
100° F (37.8° C). Which action would be most appropriate? - Answer Continue to
monitor the woman's temperature every 4 hours; this finding is normal.
The nurse is teaching parents of a 2-year-old toddler with cellulitis about temperature
measurement. Which statement by the parents demonstrates the need for further
teaching? - Answer "We should verify any fever using a rectal thermometer for
accuracy."
A nurse is monitoring a premature neonate for development of neonatal sepsis. Which
assessment finding is an early sign of neonatal sepsis? - Answer Temperature
instability
A client is being evaluated for hypothyroidism. During assessment, the nurse should
stay alert for... - Answer Decreased body temperature and cold intolerance.
A nurse is assessing a newborn's temperature. Which reading would the nurse
document as normal? - Answer 37.0° C (98.6° F)
A nurse is monitoring a client closely for malignant hyperthermia because the client
received which NMJ blocker? - Answer Succinylcholine
The nurse is teaching nursing students about the risks that late preterm infants may
experience. The nurse feels confident learning has taken place when the students make
which statement? - Answer A late preterm newborn may have more clinical problems
compared with full-term.
The nurse is preparing a teaching plan for new parents about why newborns experience
heat loss. Which information about newborns would the nurse include? - Answer
Limited voluntary muscle activity.
A nursing assessment of a client who has been diagnosed with neuroleptic malignant
syndrome (NMS) would most likely reveal which signs? - Answer Hyperpyrexia, severe
hypertension, and diaphoresis.
THERMOREGULATION) QUESTIONS
WITH COMPLETE SOLUTIONS
A nurse is caring for a preterm newborn born at 29 weeks' gestation. Which nursing
diagnosis would have the highest priority? - Answer Ineffective thermoregulation related
to decreased amount of subcutaneous fat.
Hypothermia may occur as a result of... - Answer Open body wounds.
A homeless client presents to the ED. Upon assessment, the client is experiencing
hypothermia. The nurse will plan to complete which priority intervention during the
rewarming process? - Answer Attach a cardiac monitor.
A nurse is assessing a full-term neonate and discovers a heart rate of 100 beats/minute
and an axillary temperature of 97.3°F (36.3°C). What action should the nurse take? -
Answer Place a cap on the neonate's head, and offer the neonate to the mother for
skin-to-skin.
A nurse is admitting a pregnant woman with sickle cell anemia to the emergency
department. Which findings would lead the nurse to suspect the client is in crisis? Select
all that apply. - Answer fever
joint pain
fatigue
A client in the operating room goes into malignant hyperthermia due to an abnormal
reaction to the anesthetic. The nurse knows that the area of the brain that regulates
body temperature is what? - Answer Hypothalamus
A client has a fever that was induced by damage to the hypothalamus due to inter-
cranial bleeding. The nurse plans care for which type of fever? - Answer Neurogenic
The nurse is recording vital signs in the client diagnosed with complications of anorexia
nervosa. Which findings are consistent with the condition? Select all that apply. -
Answer orthostatic hypotension
, hypothermia
weak pulse
A woman who gave birth 10 hours ago is ambulating to the bathroom and calls for
assistance with perineal care. When the nurse touches her skin, the nurse notices that
she is excessively warm. After reinforcing the woman's self-care, the nurse encourages
increased oral intake. Why was this the appropriate instruction to give to this client? -
Answer Increased intake will rehydrate the client and decrease her skin temperature.
A woman gave birth vaginally approximately 12 hours ago, and her temperature is now
100° F (37.8° C). Which action would be most appropriate? - Answer Continue to
monitor the woman's temperature every 4 hours; this finding is normal.
The nurse is teaching parents of a 2-year-old toddler with cellulitis about temperature
measurement. Which statement by the parents demonstrates the need for further
teaching? - Answer "We should verify any fever using a rectal thermometer for
accuracy."
A nurse is monitoring a premature neonate for development of neonatal sepsis. Which
assessment finding is an early sign of neonatal sepsis? - Answer Temperature
instability
A client is being evaluated for hypothyroidism. During assessment, the nurse should
stay alert for... - Answer Decreased body temperature and cold intolerance.
A nurse is assessing a newborn's temperature. Which reading would the nurse
document as normal? - Answer 37.0° C (98.6° F)
A nurse is monitoring a client closely for malignant hyperthermia because the client
received which NMJ blocker? - Answer Succinylcholine
The nurse is teaching nursing students about the risks that late preterm infants may
experience. The nurse feels confident learning has taken place when the students make
which statement? - Answer A late preterm newborn may have more clinical problems
compared with full-term.
The nurse is preparing a teaching plan for new parents about why newborns experience
heat loss. Which information about newborns would the nurse include? - Answer
Limited voluntary muscle activity.
A nursing assessment of a client who has been diagnosed with neuroleptic malignant
syndrome (NMS) would most likely reveal which signs? - Answer Hyperpyrexia, severe
hypertension, and diaphoresis.
