Module 20.2: Hypothermia (Dynamic Study)

The nurse comes upon an older adult patient outside their home who has collapsed, is not wearing a coat, and feels cool to the touch. The temperature outside is cool with a chilly breeze.

Which is the priority intervention for the nurse?

A. Place a warm towel or warm plastic bottle on the patient's trunk.

B. Begin cardiopulmonary resuscitation (CPR) immediately.

C. Apply hand warmers to the patient's hands and arms.

D. Place a hat on the patient's head.

A. Place a warm towel or warm plastic bottle on the patient's trunk.

The nurse is caring for a patient with severe frostbite of the feet.

Which is the most common cardiac dysrhythmia that occurs with excessive handling of the patient's frostbitten extremities?

A. Atrial tachycardia

B. Premature atrial contractions (PACs)

C. Ventricular fibrillation

D. Premature ventricular contractions (PVCs)

C. Ventricular fibrillation

The nurse is caring for a patient with hypothermia who is confused and disoriented.

Which factor should the nurse identify as the primary reason for the patient's disorientation?

A. Effects secondary to respiratory alkalosis

B. Decreased levels of serum carbon dioxide

C. Vasoconstriction of cerebral blood vessels

D. Vasodilation of cerebral blood vessel

C. Vasoconstriction of cerebral blood vessels

The nurse is planning care for a patient with hypothermia.

Which independent nursing intervention is appropriate?

A. Order a social worker referral.

B. Obtain the blood glucose level.

C. Administer warm IV fluids.

D. Administer warm oral fluids.

D. Administer warm oral fluids.

The nurse is completing the health history for a newly admitted patient diagnosed with hypothermia.

Which should the nurse identify as the most important health history data to assess?

A. Skin color

B. Blood pressure

C. Medications

D. Heart rate

C. Medications

A patient presents with frostbite to the left ear, nose, and feet.

Which intervention should the nurse implement?

A. Avoid handling affected areas after rewarming.

B. Massage affected areas to increase blood flow.

C. Place affected areas in the dependent position.

D. Protect and cover any blisters.

A. Avoid handling affected areas after rewarming.

A college student, brought to the emergency department by his girlfriend, has a body temperature of 94.8°F (34.9C). Which question is most important for the nurse to ask the girlfriend to help determine the patient's condition?

A. "When did you find him?"

B. "Was he drinking alcohol?"

C. "Where did you find him?"

D. "How long was he outside?"

B. "Was he drinking alcohol?"

The nurse suspects that an older adult patient with hypothermia is unable to maintain an adequate temperature at home due to financial problems.

Which intervention is most appropriate for this patient?

A. Suggest a representative from financial services see the patient.

B. Contact the patient's utility company.

C. Suggest a medical social worker see the patient.

D. Contact adult protective services.

C. Suggest a medical social worker see the patient.

Which patient should the nurse identify as having the greatest risk for hypothermia?

A. A 3-day-old infant

B. A 3-year-old

C. A 15-year-old

D. A 45-year-old

A. A 3-day-old infant

An older adult patient presents with mild hypothermia and has been initially treated with blankets and forced warm air.

Which intervention should the nurse expect to implement next?

A. Massage the patient's extremities.

B. Administer whirlpool therapy.

C. Encourage the patient to ambulate.

D. Administer warm IV fluids.

D. Administer warm IV fluids.

A patient with head trauma has been admitted with hypothermia.

Which observation should lead the nurse to expect hemodialysis will be ordered to treat this patient?

A. Damage to the renal system

B. Damage to the hypothalamus

C. Damage to the vascular system

D. Damage to the blood

B. Damage to the hypothalamus

The nurse is caring for a 17-year-old patient with hypothermia and frostbite who spent the night outside in the elements after passing out from binge drinking.

The nurse should recognize that which process increased the risk of hypothermia for this patient?

A. Alcohol causes peripheral vasodilation, causing a faster drop in body temperature.

B. Alcohol increases the viscosity of the blood, increasing the risk of ice crystals.

C. Alcohol causes peripheral vasoconstriction, causing decreased blood flow to the extremities.

D. Alcohol increases the intracellular sodium content, lowering the freezing point of the tissues.

A. Alcohol causes peripheral vasodilation, causing a faster drop in body temperature.

The nurse is caring for a patient diagnosed with hypothermia.

Which assessment finding should the nurse expect?

A. Cyanotic nail beds

B. Bounding pulse

C. Capillary refill of 2 seconds or less

D. Flushed skin

A. Cyanotic nail beds

The nurse suggests a consult with a medical social worker for an older adult patient who is reporting to the clinic for the third time in a month with signs of hypothermia. The patient asks, "Why are you suggesting this?"

Which response by the nurse is correct?

A. "The medical social worker will be able to assist with your hospital finances."

B. "The medical social worker will determine if adult protective services needs to be called."

C. "The medical social worker will work with your utility company to eliminate your heating bills."

D. "The medical social worker will assess the safety of your home environment."

D. "The medical social worker will assess the safety of your home environment."

The nurse is caring for a child after a sledding injury. The nurse suspects the child has superficial frostbite.

Which assessment finding supports the nurse's suspicion?

A. Yellow appearance of the tip of the nose

B. White appearance of the tip of the nose

C. Hallucinations

D. Presence of gangrene

B. White appearance of the tip of the nose

The healthcare provider orders a creatine kinase level analysis for a patient who has moderate hypothermia. The patient asks why this test is needed.

Which response by the nurse is accurate?

A. "The test detects the presence of bacteria in the urine."

B. "The test will tell us if your kidneys are failing."

C. "The test is to monitor for muscle breakdown, which may lead to kidney injury or failure."

D. "The test will tell us how much oxygen is circulating in your bloodstream

C. "The test is to monitor for muscle breakdown, which may lead to kidney injury or failure."

The nurse is caring for a patient recovering from hypothermia.

Which outcome should the nurse expect?

A. The patient's core temperature rises to 101.8°F (38.8°C).

B. The patient develops piloerection.

C. The patient states the need to take antipyretics at the first sign of a fever.

D. The patient is able to list early signs and symptoms of hypothermia.

D. The patient is able to list early signs and symptoms of hypothermia.

A graduate nurse is planning care for a patient diagnosed with hypothermia and frostbite. The preceptor asks, "Which intervention is performed after rewarming the patient's feet?"

Which statement by the graduate nurse indicates understanding of the next intervention?

A. "I should elevate the patient's legs on pillows."

B. "I should rub the patient's legs with lotion."

C. "I should place compression stockings on the patient's legs."

D. "I should have the patient dangle the legs off the side of the bed."

A. "I should elevate the patient's legs on pillows."

The nurse is teaching a new parent about how to protect their infant from hypothermia.

Which statement by the parent indicates that further teaching is needed?

A. "If my baby feels cool, I will wrap them in a warm blanket."

B. "If my baby feels cool, I will place a hat on their head."

C. "If my baby feels cool, I'll place them in direct sunlight with as much skin exposed as possible."

D. "I will make sure I keep my baby warm and dry at all times."

C. "If my baby feels cool, I'll place them in direct sunlight with as

An 83-year-old man lives alone on a limited income.

Which assessment should the nurse perform to determine if the man is at increased risk for hypothermia?

A. Decreased immune response

B. Giant cell arteritis

C. Financial

C. Hyperthyroidism

C. Financial

An older adult was found unresponsive in the home. The heat was off and the environment was cold. The patient has cyanotic nail beds, a weak pulse, and slow capillary refill.

Which finding should the nurse anticipate?

A. Core body temperature 98.6°F (37°C)

B. Core body temperature 82.6°F (28.1°C)

C. Core body temperature 101.8°F (38.8°C)

D. Core body temperature 106.2°F (41.2°C)

B. Core body temperature 82.6°F (28.1°C)

An older adult patient presents with hypothermia.

The nurse should consider which process as contributing to the risk for this patient?

A. The normal aging process decreases pain tolerance.

B. The normal aging process decreases safety awareness.

C. The normal aging process decreases the ability to shiver.

D. The normal aging process decreases metabolism.

D. The normal aging process decreases metabolism.

The nurse provided discharge teaching to a patient with frostbite of their nose.

Which patient response indicates the teaching was successful?

A. "I will rub the skin of my nose with a washcloth daily."

B. "I will gently message my nose several times a day."

C. "If blisters occur, I will keep them covered with a bandage."

D. "I will not touch my nose until it is fully healed."

D. "I will not touch my nose until it is fully healed."

A woman who is 26 weeks' gestation presents with a temperature of 93.9°F (34.4°C) and severe shivering.

Which nursing intervention is the priority?

A. Apply warming pads and begin fetal monitoring.

B. Support respiratory and cardiac function.

C. Place a hat on the patient's head.

D. Rapidly rewarm the affected areas in circulating warm water.

A. Apply warming pads and begin fetal monitoring.

The school nurse is giving a presentation for parents regarding hypothermia.

Which statement should the nurse include regarding the first step in treating hypothermia?

A. "Remove clothing and assess for frostbite after a day playing in the snow."

B. "Immediately administer anti-inflammatories to warm up your child."

C. "Provide dry clothing and warm blankets when your child comes in from outside."

D. "Have your child take a warm whirlpool bath."

C. "Provide dry clothing and warm blankets when your child comes in from outside."

The body's surface temperature changes continuously in response to the environment.

When considering the ways in which heat transfer occurs in the development of hypothermia, which situation is the most likely cause of excessive heat loss through convection?

A. Falling into a partially frozen lake

B. Standing outside in a sunny area

C. Placing an infant on a metal examination table

D. Sweating after completing a workout session

A. Falling into a partially frozen lake

The nurse is conducting a teaching session with a group of college students regarding alcohol consumption and the risk of hypothermia.

Which information should the nurse include in the teaching?

A. Alcohol causes peripheral vasoconstriction, which increases the rate of cooling.

B. Alcohol impacts sensory perception and the individual's ability to sense cold.

C. Alcohol causes peripheral vasodilation, which increases the rate of cooling.

D. Alcohol impacts respiratory function, which contributes to hypothermia.

C. Alcohol causes peripheral vasodilation, which increases the rate of cooling.