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The mother of preschool-age client tells the nurse that the client has frequent fevers.Which response by the nurse is appropriate?


A) "Fevers are most frequently seen in children because of developing immunity."
B) "This is unusual because common diseases of childhood rarely result in fevers."
C) "Your child must be around people with illnesses."
D) "Your child's immunity is compromised."

E) B) and C)
F) A) and B)

Correct Answer

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The nurse assists with the delivery of a newborn on the labor and delivery unit.By drying the newborn immediately after birth,the nurse is protecting heat loss by which method?


A) Convection
B) Conduction
C) Evaporation
D) Radiation

E) C) and D)
F) A) and B)

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The nurse is educating a family who is planning an ice fishing trip on ways to prevent hypothermia.Which recommendation by the nurse is appropriate?


A) All family members should wear skid-proof footwear.
B) If someone becomes hypothermic, keep the clothing on, cover the person with damp blankets, and have the person drink a cool liquid.
C) All family members should light rain jackets.
D) If someone becomes hypothermic, remove any wet clothing, wrap the person in blankets, and have the person drink a warm liquid.

E) A) and B)
F) A) and C)

Correct Answer

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An older adult client admitted with pneumonia has a normal body temperature.Which reason for this inconsistency in body temperature will the nurse plan for when providing care to this client?


A) The room is cold.
B) The client does not have pneumonia.
C) The temperature is not a valid indicator of the pathology of the illness.
D) The client is losing body heat.

E) A) and D)
F) A) and B)

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A client is admitted with the diagnosis of fever of unknown origin.Which diagnostic tests does the nurse anticipate for this client? Select all that apply.


A) CT scan of the abdomen
B) Chest x-ray
C) Urinalysis
D) Complete blood count
E) Bone scan

F) C) and E)
G) B) and E)

Correct Answer

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A nurse working in labor and delivery is aware that newborns have several physiologic mechanisms that increase heat production to prevent hypothermia.What is true regarding newborn thermogenesis?


A) Shivering occurs when skin receptors perceive a drop in the environmental temperature and transmit sensations to stimulate the sympathetic nervous system.
B) Shivering thermogenesis uses the newborn's stores of brown fat to provide heat.
C) Brown fat produces heat generation, and heat transfer to the peripheral circulation.
D) The extra muscular activity by the infant in cold stress produces a large amount of body heat.

E) A) and C)
F) C) and D)

Correct Answer

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A client is admitted to the emergency department with a body temperature of 103°F.It is a hot and humid day,and the client works in a factory with no air conditioning.Which actions by the nurse are appropriate when providing care to this client? Select all that apply.


A) Use warm blankets.
B) Restrict fluids.
C) Apply cool washcloths to the face and neck.
D) Assess vital signs.
E) Remove or loosen clothing around the neck and chest.

F) D) and E)
G) A) and B)

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C,E

The nurse is providing care to a client who has a body temperature of 94°F,an irregular heart rate,and low blood pressure.Which is the priority intervention for this client?


A) Elevate the client's legs.
B) Provide a heating pad to the client's lower back.
C) Elevate the head of the bed.
D) Administer warmed intravenous fluids.

E) A) and C)
F) B) and C)

Correct Answer

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D

A young adult client is admitted to the emergency department with symptoms of hypothermia.Which data collected during the health history supports this diagnosis? Select all that apply.


A) Wearing sandals
B) Consuming alcohol
C) Walking outdoors in 30°F weather
D) Wearing a hat
E) Standing outdoors during a snow storm without a coat

F) C) and D)
G) B) and E)

Correct Answer

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A nurse educator is teaching a group of student nurses regarding heat and cold injuries.Which statement will the nurse include about thermoregulation?


A) "Core temperature varies widely depending on the outside environment."
B) "The body's surface temperature remains relatively constant."
C) "Chemical thermogenesis occurs with the increase of cortisol."
D) "All muscle activity, regardless of location, produces heat."

E) A) and B)
F) A) and C)

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A client is receiving care for an elevated body temperature.Which assessment findings indicate that care has been effective? Select all that apply.


A) Urine output of 20 ml/hour
B) Moist mucous membranes
C) Heart rate of 120 beats per minute
D) Good skin turgor
E) Blood pressure of 118/68 mmHg

F) D) and E)
G) A) and B)

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A nurse working in an outpatient pediatric clinic is speaking to the mother of a school-age client who has a temperature of 101°F.Which statement should the nurse include when instructing the mother on treatment of the fever?


A) "Place the child in a cold bath."
B) "Administer aspirin by either chewable tablet or liquid suspension."
C) "It is not necessary to treat the fever at this point."
D) "If your child is shivering, it is okay to use several blankets to decrease discomfort."

E) A) and C)
F) All of the above

Correct Answer

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During an assessment,the nurse notes that a client who was a victim of an industrial accident has a mildly elevated body temperature.When discussing the client's increased temperature,which will the nurse attribute it to?


A) Infection
B) Diet
C) Exercise
D) Stress

E) A) and B)
F) A) and C)

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A client is admitted with a core body temperature of 93°F.Which action by the nurse is appropriate for this client?


A) Apply warm soaks to the extremities.
B) Use a hyperthermia blanket.
C) Provide warm fluids.
D) Use warm blankets.

E) B) and D)
F) A) and D)

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The nurse is planning to instruct a new mother on ways to prevent hypothermia in her newborn.What should this teaching include? Select all that apply.


A) Expect the baby to shiver.
B) Keep the newborn's head covered.
C) Cover the newborn with a light sheet during afternoon naps.
D) Notice changes in the baby's respirations and take the appropriate action.
E) Cover the newborn with minimal blankets when out of doors in temperatures in the 50s.

F) C) and D)
G) A) and E)

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A client is started on antibiotic therapy for a respiratory infection.Which goal is appropriate for this client?


A) The client will have no evidence of sweating.
B) The client's mucus membranes will be dry.
C) The client's temperature will be within normal limits within 48 to 72 hours of the administration of the antibiotic.
D) The client's temperature will approach normal within 60 minutes of the administration of the antibiotic.

E) A) and B)
F) A) and C)

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The nurse assesses a client's temperature to be 99.8°F.Which nursing diagnosis would be appropriate for the client at this time?


A) Hyperthermia
B) Anxiety
C) Risk for Imbalanced Body Temperature
D) Deficient Fluid Volume

E) A) and B)
F) A) and C)

Correct Answer

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The nurse is caring for a client admitted with minor burns and elevated body temperature after being in a house fire.What should be included in this client's plan of care? Select all that apply.


A) Providing blankets
B) Keeping the room temperature warm
C) Restricting fluids
D) Encouraging fluids
E) Lowering room temperature

F) None of the above
G) B) and C)

Correct Answer

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A nurse is caring for a client with hypothermia and frostbite of the nose and fingers.Which action by the nurse is inappropriate for this client?


A) Massage frostbite areas to rewarm them and increase circulation.
B) Rapidly rewarm affected areas in circulating warm water.
C) Keep the client on bedrest with the affected parts elevated.
D) Debride blisters.

E) None of the above
F) A) and B)

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The nurse needs to assess the body temperature of a client who has just smoked a cigarette and consumed hot coffee.Which temperature assessment method should the nurse use?


A) Axillary
B) Temporal artery
C) Tympanic
D) Rectal

E) A) and B)
F) C) and D)

Correct Answer

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C

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