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 D
Explanation
A. Document the findings in the patient's medical record. While documentation is important, further assessment is needed before determining if the blood pressure is abnormal for this patient.
B. Apply a cool washcloth to the patient's forehead. The patient’s temperature is normal (98.9°F), so there is no need for cooling measures.
C. Administer oxygen at 2 L/minute via nasal cannula. The pulse oximetry is 94%, which is adequate for most patients. Oxygen is not needed unless the patient shows signs of respiratory distress.
D. Ask the patient about his usual blood pressure results. The blood pressure (144/94 mmHg) is elevated, but before determining if intervention is needed, the nurse should ask if this is typical for the patient or if it is an isolated finding.
Correct Answer is D
Explanation
A. 4+. A 4+ pulse is bounding and strong, often seen in conditions like fever, anemia, or fluid overload. This does not match the description of a weak pulse.
B. 3+. A 3+ pulse is stronger than normal but not bounding. This is not considered weak.
C. 2+. A 2+ pulse is normal and easily palpable, which does not indicate the weakened pulse described in the patient.
D. 1+. A 1+ pulse is weak and thready, meaning it is difficult to palpate and easily disappears with slight pressure. This grading is appropriate for a hypotensive patient with poor perfusion.
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