ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 29 Questions
Question 1 of 5
A patient has a head injury and damages the hypothalamus. Which vital sign will the nurse monitor most closely?
Correct Answer: B
Rationale: The hypothalamus regulates body temperature, so damage from a head injury disrupts thermoregulation, potentially causing hypo- or hyperthermia. Monitoring temperature (
B) is critical to detect these shifts, which can indicate injury severity or complications like fever from inflammation. Pulse (
A) reflects cardiac response but isn't directly hypothalamic. Respirations (
C) may change secondary to brain injury but aren't primarily hypothalamic. Blood pressure (
D) can fluctuate with intracranial pressure, yet temperature is the most directly affected vital sign here.
Choice B is correct as it aligns with the hypothalamus's role in maintaining thermal homeostasis, a priority in neuro nursing to prevent further brain damage or systemic issues.
Question 2 of 5
The patient is lying in bed under a ceiling fan. Which technique is the nurse using when the fan produces heat loss?
Correct Answer: C
Rationale: A ceiling fan moves air over the patient, causing heat loss via convection (
C), where warm air around the body is replaced by cooler moving air. Radiation (
A) involves heat emission without contact, not fan-driven. Conduction (
B) requires direct contact (e.g., cold pack), not air movement. Evaporation (
D) involves moisture loss, not primarily fan-related here.
Choice C is correct because convection matches the mechanism of air circulation enhancing heat dissipation, a principle nurses apply in thermoregulation strategies to cool patients effectively in clinical settings.
Question 3 of 5
The patient has a temperature of 105.2?°F. The nurse is attempting to lower temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. Which technique is the nurse using to lower the patient's temperature?
Correct Answer: B
Rationale: Tepid sponge baths and cool compresses lower temperature via conduction (
B), transferring heat from the skin to the cooler objects through direct contact. Radiation (
A) involves heat loss to the environment without contact, not the primary method here. Convection (
C) requires air movement (e.g., fans), not used. Evaporation (
D) occurs with moisture vaporizing, a minor effect with tepid water but not dominant.
Choice B is correct as conduction is the main mechanism, aligning with nursing interventions to reduce fever by physically drawing heat away from the body.
Question 4 of 5
The nurse needs to increase heat conservation in a newborn. Which action will the nurse take?
Correct Answer: C
Rationale: Newborns lose heat rapidly, especially from the head, due to a large surface area and limited thermoregulation. Placing a cap (
C) conserves heat by covering this key area, a standard neonatal practice. A diaper alone (
A) offers minimal coverage, increasing heat loss. Doubling clothing (
B) helps but is less effective than a cap for head protection. Raising the room to 90?°F (
D) risks overheating.
Choice C is correct, supported by pediatric guidelines (e.g., AAP) emphasizing head coverage to maintain newborn temperature stability.
Question 5 of 5
The nurse is working the night shift on a surgical unit and notices that the patient's temperature is 96.8?°F (36?°C), whereas at 4:00 PM the preceding day, it was 98.6?°F (37?°C). What should the nurse do?
Correct Answer: D
Rationale: A temperature of 96.8?°F (36?°
C) is slightly low but within normal diurnal variation (lowest at night). Waiting 30 minutes to recheck (
D) confirms if it's a trend or artifact, avoiding overreaction. Calling the provider (
A) is premature for a non-critical value without symptoms. Lowering it further (
B) is illogical for hypothermia. Adding a blanket (
C) assumes hypothermia without confirmation.
Choice D is correct, reflecting nursing judgment to monitor trends, aligning with circadian temperature dips and post-surgical assessment protocols.