NURS 270 Unit 4 UPDATED ACTUAL Questions
and CORRECT Answers
A child is about to be admitted to the pediatric intensive care unit (PICU) after surgery for removal of a tumor in the
hypothalamic region of the brain. The nurse manager should intervene immediately when the child's nurse
A. Places a hypothermia blanket at the bedside.
B. Adjusts the bed to the Trendelenburg position.
C. Obtains electronic equipment for monitoring the vital signs.
D. Secures a pump to administer the ordered intravenous fluids. - CORRECT ANSWER B. Adjusts the bed to the
Trendelenburg position.
It is not safe to put the bed in the Trendelenburg position, because raising the foot increases blood flow to the brain,
thereby increasing intracranial pressure. Temperature elevations may occur after a craniotomy because of stimulation of
the hypothalamus. A hypothermic blanket should be ready if the temperature becomes precipitously elevated. Monitoring
vital signs is a critical component of postoperative care. Intravenous infusions must be regulated precisely to minimize the
possibility of cerebral edema.
A patient with hypothermia is brought to the emergency department. The nurse should explain to the family members that
treatment will include
A. Core rewarming with warm fluids.
B. Ambulation to increase metabolism.
C. Frequent oral temperature assessment.
D. Gastric tube feedings to increase fluids. - CORRECT ANSWER A. Core rewarming with warm fluids.
Core rewarming with heated oxygen and administration of warmed oral or intravenous fluids is the preferred method of
treatment. The patient would be too weak to ambulate. Oral temperatures are not the most accurate assessment of core
temperature because of environmental influences. Warmed oral feedings are advised; gastric gavage is unnecessary.
What clinical indicator will the nurse most likely identify when assessing a patient with pyrexia?
A. Dyspnea.
B. Precordial pain.
C. Increased pulse rate.
D. Elevated blood pressure. - CORRECT ANSWER C. Increased pulse rate.
The pulse rate increases to meet increased tissue demands for oxygen in the febrile state. Fever may increase but does not
cause difficulty in breathing. Pain is not related to fever. Blood pressure is not necessarily elevated in fever.
A homeless person is brought to the emergency department after prolonged exposure to cold weather. The nurse would
assess the patient for manifestations of hypothermia, including
A. Stupor.
B. Erythema.
C. Increased anxiety.
D. Rapid respirations. - CORRECT ANSWER A. Stupor.
Stupor may occur with hypothermia because of slowed cerebral metabolic processes. Pallor, not erythema, would be
present as a result of peripheral vasoconstriction. Drowsiness occurs; the patient would be unable to focus on anxiety-
producing aspects of the situation. Respirations would be decreased.
A priority nursing intervention for a patient with hyperthermia would be
A. Initiating seizure precautions.
B. Limiting oral intake.
C. Providing a blanket.
D. Removing excess clothing. - CORRECT ANSWER D. Removing excess clothing.
Rationale
,The priority nursing intervention would be removal of excess clothing. Seizures may occur because of a high body
temperature, but seizure precautions should not be the first intervention. Oral intake, especially of fluids, should not be
limited for a patient with hyperthermia, because of the dangers of dehydration. Blanketing, like clothing, should be
removed.
The nurse admitting a patient to the emergency room on a cold winter night would suspect hypothermia when the patient
demonstrates
A. Increased respirations.
B. Rapid pulse rate.
C. Red, sweaty skin.
D. Slow capillary refill. - CORRECT ANSWER D. Slow capillary refill.
With hypothermia, there is slow capillary refill. There is an increased respiration rate with hyperthermia. The heart rate
increases with hyperthermia. The skin is usually pale or cyanotic with hypothermia.
The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes
that the client's temperature is 100.2° F. What is the priority nursing action?
1. Document the findings.
2. Retake the temperature in 15 minutes.
3. Notify the health care provider (HCP).
4. Increase hydration by encouraging oral fluids. - CORRECT ANSWER 4
The nurse has just administered ibuprofen (Motrin) to a child with a temperature of 38.8° C (102° F). The nurse should
also take which action?
1. Withhold oral fluids for 8 hours.
2. Sponge the child with cold water.
3. Plan to administer salicylate (aspirin) in 4 hours.
4. Remove excess clothing and blankets from the child. - CORRECT ANSWER 4
The nurse is caring for a child after surgical removal of a brain tumor. The nurse should assess the child for which sign
that would indicate that brainstem involvement occurred during the surgical procedure?
1. Inability to swallow
2. Elevated temperature
3. Altered hearing ability
4. Orthostatic hypotension - CORRECT ANSWER 2
A client with a neurological problem is experiencing hyperthermia. Which measure would be least appropriate for the
nurse to use in trying to lower the client's body temperature?
1. Giving tepid sponge baths
2. Applying a hypothermia blanket
3. Placing ice packs in the axilla and groin areas
4. Administering acetaminophen (Tylenol) per protocol - CORRECT ANSWER 3
The nurse has applied a hypothermia blanket to a client with a fever. A priority for the nurse is to inspect the skin
frequently to detect which complication of hypothermia blanket use?
1. Frostbite
2. Skin breakdown
3. Venous insufficiency
4. Arterial insufficiency - CORRECT ANSWER 2
The nurse is performing an assessment on a client with a diagnosis of myxedema (hypothyroidism). Which assessment
finding should the nurse expect to note in this client?
, 1. Dry skin
2. Thin, silky hair
3. Bulging eyeballs
4. Fine muscle tremors - CORRECT ANSWER 1
The nurse is performing an assessment on a client with a diagnosis of hyperthyroidism. Which assessment finding should
the nurse expect to note in this client?
1. Dry skin
2. Bulging eyeballs
3. Periorbital edema
4. Coarse facial features - CORRECT ANSWER 2
A client arrives at the postpartum unit after delivery of her infant. On performing an assessment, the nurse notes that the
client is shaking uncontrollably. Which nursing action would be appropriate?
1. Massage the fundus.
2. Contact the health care provider.
3. Cover the client with a warm blanket.
4. Place the client in Trendelenburg's position - CORRECT ANSWER 3
The nurse is monitoring a client with Graves' disease for signs of thyrotoxic crisis (thyroid storm). Which signs or
symptoms, if noted in the client, will alert the nurse to the presence of this crisis?
1. Fever and tachycardia
2. Pallor and tachycardia
3. Agitation and bradycardia
4. Restlessness and bradycardia - CORRECT ANSWER 1
The nursing instructor asks a nursing student to identify the risk factors associated with the development of
thyrotoxicosis. The student demonstrates understanding of the risk factors by identifying an increased risk for
thyrotoxicosis in which client?
1. A client with hypothyroidism
2. A client with Graves' disease who is having surgery
3. A client with diabetes mellitus scheduled for a diagnostic test
4. A client with diabetes mellitus scheduled for débridement of a foot ulcer - CORRECT ANSWER 2
The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who is experiencing night fever and
night sweats. Which nursing intervention would be the least helpful in managing this symptom?
1. Keep liquids at the bedside.
2. Make sure the pillow has a plastic cover.
3. Keep a change of bed linens nearby in case they are needed.
4. Administer an antipyretic after the client has a spike in temperature. - CORRECT ANSWER 4
The nurse is caring for an unconscious client who is experiencing persistent hyperthermia with no signs of infection. The
nurse interprets that the hyperthermia may be related to damage to the client's thermoregulatory center in which structure?
1. Cerebrum
2. Cerebellum
3. Hippocampus
4. Hypothalamus - CORRECT ANSWER 4
A nurse has a prescription to administer a medication to a client who is experiencing shivering as a result of
hyperthermia. Which medication should the nurse anticipate to be prescribed?
1. Buspirone (BuSpar)
2. Chlorpromazine (Thorazine)
3. Prochlorperazine (Compazine)
and CORRECT Answers
A child is about to be admitted to the pediatric intensive care unit (PICU) after surgery for removal of a tumor in the
hypothalamic region of the brain. The nurse manager should intervene immediately when the child's nurse
A. Places a hypothermia blanket at the bedside.
B. Adjusts the bed to the Trendelenburg position.
C. Obtains electronic equipment for monitoring the vital signs.
D. Secures a pump to administer the ordered intravenous fluids. - CORRECT ANSWER B. Adjusts the bed to the
Trendelenburg position.
It is not safe to put the bed in the Trendelenburg position, because raising the foot increases blood flow to the brain,
thereby increasing intracranial pressure. Temperature elevations may occur after a craniotomy because of stimulation of
the hypothalamus. A hypothermic blanket should be ready if the temperature becomes precipitously elevated. Monitoring
vital signs is a critical component of postoperative care. Intravenous infusions must be regulated precisely to minimize the
possibility of cerebral edema.
A patient with hypothermia is brought to the emergency department. The nurse should explain to the family members that
treatment will include
A. Core rewarming with warm fluids.
B. Ambulation to increase metabolism.
C. Frequent oral temperature assessment.
D. Gastric tube feedings to increase fluids. - CORRECT ANSWER A. Core rewarming with warm fluids.
Core rewarming with heated oxygen and administration of warmed oral or intravenous fluids is the preferred method of
treatment. The patient would be too weak to ambulate. Oral temperatures are not the most accurate assessment of core
temperature because of environmental influences. Warmed oral feedings are advised; gastric gavage is unnecessary.
What clinical indicator will the nurse most likely identify when assessing a patient with pyrexia?
A. Dyspnea.
B. Precordial pain.
C. Increased pulse rate.
D. Elevated blood pressure. - CORRECT ANSWER C. Increased pulse rate.
The pulse rate increases to meet increased tissue demands for oxygen in the febrile state. Fever may increase but does not
cause difficulty in breathing. Pain is not related to fever. Blood pressure is not necessarily elevated in fever.
A homeless person is brought to the emergency department after prolonged exposure to cold weather. The nurse would
assess the patient for manifestations of hypothermia, including
A. Stupor.
B. Erythema.
C. Increased anxiety.
D. Rapid respirations. - CORRECT ANSWER A. Stupor.
Stupor may occur with hypothermia because of slowed cerebral metabolic processes. Pallor, not erythema, would be
present as a result of peripheral vasoconstriction. Drowsiness occurs; the patient would be unable to focus on anxiety-
producing aspects of the situation. Respirations would be decreased.
A priority nursing intervention for a patient with hyperthermia would be
A. Initiating seizure precautions.
B. Limiting oral intake.
C. Providing a blanket.
D. Removing excess clothing. - CORRECT ANSWER D. Removing excess clothing.
Rationale
,The priority nursing intervention would be removal of excess clothing. Seizures may occur because of a high body
temperature, but seizure precautions should not be the first intervention. Oral intake, especially of fluids, should not be
limited for a patient with hyperthermia, because of the dangers of dehydration. Blanketing, like clothing, should be
removed.
The nurse admitting a patient to the emergency room on a cold winter night would suspect hypothermia when the patient
demonstrates
A. Increased respirations.
B. Rapid pulse rate.
C. Red, sweaty skin.
D. Slow capillary refill. - CORRECT ANSWER D. Slow capillary refill.
With hypothermia, there is slow capillary refill. There is an increased respiration rate with hyperthermia. The heart rate
increases with hyperthermia. The skin is usually pale or cyanotic with hypothermia.
The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes
that the client's temperature is 100.2° F. What is the priority nursing action?
1. Document the findings.
2. Retake the temperature in 15 minutes.
3. Notify the health care provider (HCP).
4. Increase hydration by encouraging oral fluids. - CORRECT ANSWER 4
The nurse has just administered ibuprofen (Motrin) to a child with a temperature of 38.8° C (102° F). The nurse should
also take which action?
1. Withhold oral fluids for 8 hours.
2. Sponge the child with cold water.
3. Plan to administer salicylate (aspirin) in 4 hours.
4. Remove excess clothing and blankets from the child. - CORRECT ANSWER 4
The nurse is caring for a child after surgical removal of a brain tumor. The nurse should assess the child for which sign
that would indicate that brainstem involvement occurred during the surgical procedure?
1. Inability to swallow
2. Elevated temperature
3. Altered hearing ability
4. Orthostatic hypotension - CORRECT ANSWER 2
A client with a neurological problem is experiencing hyperthermia. Which measure would be least appropriate for the
nurse to use in trying to lower the client's body temperature?
1. Giving tepid sponge baths
2. Applying a hypothermia blanket
3. Placing ice packs in the axilla and groin areas
4. Administering acetaminophen (Tylenol) per protocol - CORRECT ANSWER 3
The nurse has applied a hypothermia blanket to a client with a fever. A priority for the nurse is to inspect the skin
frequently to detect which complication of hypothermia blanket use?
1. Frostbite
2. Skin breakdown
3. Venous insufficiency
4. Arterial insufficiency - CORRECT ANSWER 2
The nurse is performing an assessment on a client with a diagnosis of myxedema (hypothyroidism). Which assessment
finding should the nurse expect to note in this client?
, 1. Dry skin
2. Thin, silky hair
3. Bulging eyeballs
4. Fine muscle tremors - CORRECT ANSWER 1
The nurse is performing an assessment on a client with a diagnosis of hyperthyroidism. Which assessment finding should
the nurse expect to note in this client?
1. Dry skin
2. Bulging eyeballs
3. Periorbital edema
4. Coarse facial features - CORRECT ANSWER 2
A client arrives at the postpartum unit after delivery of her infant. On performing an assessment, the nurse notes that the
client is shaking uncontrollably. Which nursing action would be appropriate?
1. Massage the fundus.
2. Contact the health care provider.
3. Cover the client with a warm blanket.
4. Place the client in Trendelenburg's position - CORRECT ANSWER 3
The nurse is monitoring a client with Graves' disease for signs of thyrotoxic crisis (thyroid storm). Which signs or
symptoms, if noted in the client, will alert the nurse to the presence of this crisis?
1. Fever and tachycardia
2. Pallor and tachycardia
3. Agitation and bradycardia
4. Restlessness and bradycardia - CORRECT ANSWER 1
The nursing instructor asks a nursing student to identify the risk factors associated with the development of
thyrotoxicosis. The student demonstrates understanding of the risk factors by identifying an increased risk for
thyrotoxicosis in which client?
1. A client with hypothyroidism
2. A client with Graves' disease who is having surgery
3. A client with diabetes mellitus scheduled for a diagnostic test
4. A client with diabetes mellitus scheduled for débridement of a foot ulcer - CORRECT ANSWER 2
The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who is experiencing night fever and
night sweats. Which nursing intervention would be the least helpful in managing this symptom?
1. Keep liquids at the bedside.
2. Make sure the pillow has a plastic cover.
3. Keep a change of bed linens nearby in case they are needed.
4. Administer an antipyretic after the client has a spike in temperature. - CORRECT ANSWER 4
The nurse is caring for an unconscious client who is experiencing persistent hyperthermia with no signs of infection. The
nurse interprets that the hyperthermia may be related to damage to the client's thermoregulatory center in which structure?
1. Cerebrum
2. Cerebellum
3. Hippocampus
4. Hypothalamus - CORRECT ANSWER 4
A nurse has a prescription to administer a medication to a client who is experiencing shivering as a result of
hyperthermia. Which medication should the nurse anticipate to be prescribed?
1. Buspirone (BuSpar)
2. Chlorpromazine (Thorazine)
3. Prochlorperazine (Compazine)
