The client has been hospitalized after a severe head injury. The nurse recognizes that the client's difficulty in maintaining a normal body temperature when there is no infection present can be the result of which of these?
Errors by the nurse assistant in measuring temperature
Increased vasodilatation of the superficial vessels contributing to excess heat losses
The client's head injury causing interference with the function of the hypothalamus
Choosing the wrong time of day to obtain vital signs
The Correct Answer is C
A. Errors by the nurse assistant in measuring temperature. While improper technique can lead to inaccurate readings, consistent temperature fluctuations in a head injury patient are more likely due to hypothalamic dysfunction.
B. Increased vasodilatation of the superficial vessels contributing to excess heat losses. Vasodilation can play a role in heat loss, but it does not fully explain difficulty maintaining body temperature, which is primarily regulated by the hypothalamus.
C. The client's head injury causing interference with the function of the hypothalamus. The hypothalamus regulates body temperature, and a severe head injury can disrupt this function, leading to temperature instability (neurogenic fever or hypothermia) despite the absence of infection.
D. Choosing the wrong time of day to obtain vital signs. While body temperature naturally fluctuates throughout the day, major instability in temperature regulation is not due to the timing of measurement but rather an issue with the hypothalamus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["3"]
Explanation
Calculation:
To determine the number of capsules per dose, use the formula:
Capsules per dose = Dose ordered/ Dose available
Given:
- Ordered dose = 600 mg
- Available dose = 200 mg per capsule
Capsules per dose = 600mg/ (200mg/capsule)
= 3 capsules
Thus, the nurse will administer 3 capsules per dose.
Correct Answer is C
Explanation
A. Auscultation. Auscultation involves listening to internal body sounds, usually with a stethoscope, such as heart, lung, or bowel sounds. It is not used for assessing the radial pulse.
B. Percussion. Percussion is the technique of tapping on body surfaces to assess underlying structures, such as detecting fluid in the lungs or assessing organ size. It is not used to assess pulses.
C. Palpation. Palpation involves using the fingers to feel for the radial pulse by applying gentle pressure over the radial artery at the wrist. This is the correct method for assessing a patient's radial pulse.
D. Inspection. Inspection involves visually examining the patient for abnormalities such as skin color, swelling, or deformities. It does not provide information about pulse rate or rhythm.
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