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Which statement correctly defines hyperthermia?
- A. Hyperthermia is a downward shift in the set point.
- B. Hyperthermia is an upward shift in the set point.
- C. Hyperthermia occurs when the body cannot reduce heat production.
- D. Hyperthermia results from a reduction in thermoregulatory mechanisms.
Correct Answer: C
Rationale: Hyperthermia is an uncontrolled rise in body temperature when heat production exceeds dissipation (C), often from external factors or exertion, not set-point shifts. A downward set-point shift (A) isn't hyperthermia. An upward shift (B) defines fever, not hyperthermia. Reduced mechanisms (D) may contribute but isn't the definition. Choice C is correct, distinguishing hyperthermia from fever per nursing pathophysiology, critical for appropriate interventions.
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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?
- A. Call the health care provider immediately to report a possible infection.
- B. Administer medication to lower the temperature further.
- C. Provide another blanket to conserve body temperature.
- D. Wait 30 minutes and recheck the patient's temperature.
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.
The nurse is preparing to assess the blood pressure of a 3 year old. How should the nurse proceed?
- A. Use the diaphragm portion of the stethoscope to detect Korotkoff sounds.
- B. Obtain the reading before the child has a chance to 'settle down.'
- C. Choose the cuff that says 'Child' instead of 'Infant.'
- D. Explain the procedure to the child.
Correct Answer: D
Rationale: For a 3-year-old, explaining the procedure (D) reduces anxiety, improving cooperation. Diaphragm (A) is less effective than the bell for Korotkoff sounds. Pre-settling (B) risks agitation. Child cuff (C) is correct but secondary. Choice D is correct, per pediatric nursing communication strategies.
What is the primary purpose of pulse assessment?
- A. Assessing changes in blood pressure
- B. Assessing changes in body temperature
- C. Assessing changes in cardiac status
- D. Assessing changes in respiratory status
Correct Answer: C
Rationale: Pulse assessment primarily evaluates cardiac status (C), reflecting heart rate and rhythm, key indicators of cardiovascular function. Blood pressure (A) relates but requires a cuff. Temperature (B) isn't pulse-related. Respiratory status (D) is secondary. Choice C is correct, per nursing fundamentals, as pulse directly monitors heart performance, guiding cardiac care.
The nurse is providing a blood pressure clinic for the community. Which group will the nurse most likely address?
- A. Non-Hispanic Caucasians
- B. European Americans
- C. African Americans
- D. Asian Americans
Correct Answer: C
Rationale: African Americans (C) have higher hypertension prevalence (e.g., AHA data), making them a priority for BP clinics. Other groups (A, B, D) have lower rates. Choice C is correct, reflecting public health focus on at-risk populations for cardiovascular screening.
The patient is admitted with shortness of breath and chest discomfort. Which laboratory value could account for the patient's symptoms?
- A. Red blood cell count of 5.0 million/mm3
- B. Hemoglobin level of 8.0 g/100 mL
- C. Hematocrit level of 45%
- D. Pulse oximetry of 95%
Correct Answer: B
Rationale: Shortness of breath and chest discomfort suggest reduced oxygen delivery. Hemoglobin of 8.0 g/dL (B) indicates anemia (normal 12-16 g/dL), impairing oxygen transport. RBC 5.0 million/mm3 (A) and hematocrit 45% (C) are normal. Oximetry 95% (D) is adequate. Choice B is correct, linking anemia to symptoms per nursing pathophysiology.