Giddens Concept 10: Thermoregulation

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.

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.

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.

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.

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.

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 park

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.

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.

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

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.

Which similar exemplar should the nurse consider when planning care for a patient with hypothermia?

a. Heat exhaustion

b. Heat stroke

c. Infection

d. Prematurity

ANS: D

Prematurity, frostbite, 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.