Thermoregulation is the process of temperature regulation through a balance of heat production and heat loss. This balance is controlled by the hypothalamus and is similar to a thermostat. To decrease the body temperature, the hypothalamus sends out impulses to reduce body temperature by activating compensatory mechanisms such as peripheral vasodilation, sweating, and inhibition of heat production. To increase the body temperature, the hypothalamus sends out impulses to increase heat production and reduce heat loss by causing shivering, the release of epinephrine (which increases metabolism), the blood vessels constrict(moving blood away from the periphery (where heat is lost) to the core of the body, and piloerection (hairs standing on end). There is also Behavioral control of temperature where people add clothing when cold or remove clothing when hot.
2. Convert between the Fahrenheit and centigrade (Celsius) temperatures.
To convert from Fahrenheit to centigrade: subtract 32 from Fahrenheit and multiply by 5/9. To convert to Fahrenheit from centigrade: multiply the temperature by 9/5, and add 32.
3. Explain the physiological mechanism for a fever (pyrexia � an abnormally high body temperature).
When a bacteria or other foreign substance enters the body, phagocytes (specialized white blood cells) ingest the invaders and secrete pyrogens. Pyrogens (fever producing substances) induce the secretion of prostaglandins that reset the hypothalamus at as higher temperature causing vasoconstriction, increased metabolism, and shivering to increase the body temperature. When the stressor is removed, the hypothalamus resets the body temperature to normal. The three phases of fever are: 1. the initial phase, in which the temperature is rising by has not reached the new set point (person feels chill, shivers, and may be generally uncomfortable) 2. The second phase, in which the body temperature reaches its maximum (set point) and remains constant at the new higher level (person feels warm and dry and it may last a few days to a few weeks) 3. The third phase, in which the temperature returns to normal (person feels warm and is flushed as a result of vasodilation, diaphoresis occurs and the fever is �breaking� The are four types of fever: 1.intermittent, which alternates between regular temperature and fever 2. remittent, which fluctuates wildly but all above normal temperatures during a 24 hour period 3. constant or sustained, which the temperature may fluctuate slightly but is always above normal 4.relapsing, which has short periods of fever with alternating periods of normal temperature each lasting for 1-2 days.
4. Describe the four nursing interventions for a patient with a fever.
Fever Treatment, Malignant Hyperthermia Precautions, Temperature Regulation, Temperature Regulation: Intraoperative, and Vital Signs Monitoring.
5. Describe the methods for obtaining peripheral and apical pulses.
To access the apical pulse, auscultate and count the number of heartbeats at the apex of the heart � each �lub & dub� is one heartbeat. There are six peripheral pulse sites: Radial (most common), Brachial (use when doing CPR on infants), Carotid (used when performing CPR on adults), Femoral (use to determine circulation of the legs and on children and infants), Dorsalis pedis (peripheral circulation), and Popliteal artery (assessing circulation).
6. Explain how respirations are regulated in the body.
The two processes of respiration are mechanical and chemical. Breathing or pulmonary ventilation is the mechanical aspect of respiration where air is actively moved into and out of the respiratory system. The chemical aspects of respiration are: external respiration (the exchange of oxygen and carbon dioxide between the alveoli and the pulmonary blood supply), gas transport (the transport of oxygen and carbon dioxide throughout the body), and internal respiration (the exchange of oxygen and carbon dioxide between the capillaries and the body tissue cells).
7. Define arterial oxygen saturation.
Arterial oxygen saturation is the amount of oxygen in arterial blood.
8. Define hypoxia.
Hypoxia is inadequate cellular oxygenation.
9. Define hyperventilation.
Hyperventilation occurs when rapid and deep breathing results in excess loss of carbon dioxide.
10. Define hypoventilation.
Hypoventilation occurs when the rate and depth of respirations are decreased and carbon dioxide is retained or alveolar ventilation is compromised.
11. Discuss at least five nursing interventions for the client with impaired respiratory status.
Deep, regular breathing (promotes ventilation and optimizes gas exchange), disease screening and prevention (immunization), positioning (sitting up pulls organs down and elongates them so there is more room for air in the lungs), incentive spirometry(gives the patient a goal to strive for) , and preventing aspiration(keeping lungs clear).
12. Discuss the importance of cuff size when obtaining a blood pressure reading.
The width of the bladder of the cuff should cover 2/3 the length of the upper arm of an adult and the entire upper arm of a child. Using the incorrect size cuff can give an error of as much as 30 mmHg; if the cuff is too narrow, you will get an unusually high reading; if it is too wide, you will get a too low reading; and if you must use a cuff of improper size, use the larger size and document the cuff size.
13. Define hypotension.
Hypotension is abnormally low blood pressure and is likely to occur from dehydration or recent blood loss.
14. Define hypertension.
Hypertension is a persistently higher than normal BP.
15. Define essential hypertension.
Essential hypertension is diagnosed when there is no known cause for the BP elevation.
16. Define secondary hypertension.
Secondary hypertension is diagnosed when there is a clearly identified cause for the persistent rise in BP.
17. Which age groups are most susceptible to thermoregulation problems, and why?
Infants and older adults are most susceptible to the effects of environmental temperatures. Infants lose approximately 30% of their body heat through the head, which is proportionally larger with respect to their body than the heads of adults. Older adults have difficulty maintaining body heat because of decreased metabolism, decreased vasomotor control, and loss of subcutaneous tissue.
18. List five factors that affect body temperature.
Correct answers include developmental level, circadian rhythm, environmental temperature, hormones, emotions and stress, stimulation of the sympathetic nervous system, and increased production of epinephrine and norepinephrine.
19. What are the compensatory mechanisms for decreasing body temperature?
Peripheral vasodilation, sweating, and inhibition of heat production are mechanisms that decrease body temperature.
20. What are the compensatory mechanisms for increasing body temperature?
Vasoconstriction, release of epinephrine, and shivering are mechanisms that increase body temperature. Piloerection occurs, but it is an important heat conservation in hairy animals, not in humans.
21. For the following, would you expect the pulse rate to be greater or less than the normal adult rate of 80 bpm?
A healthy, professional tennis player�less than normal
22 For the following, would you expect the pulse rate to be greater or less than the normal adult rate of 80 bpm?
A newborn infant�greater than normal
23. For the following, would you expect the pulse rate to be greater or less than the normal adult rate of 80 bpm?
An adolescent who has just finished running track�greater than normal
24. For the following, would you expect the pulse rate to be greater or less than the normal adult rate of 80 bpm?
A client who just undergone a painful procedure�greater than normal
25. For the following, would you expect the pulse rate to be greater or less than the normal adult rate of 80 bpm?
A client with a fever�greater than normal
26. For the following, would you expect the pulse rate to be greater or less than the normal adult rate of 80 bpm?
An accident victim who is hemorrhaging�greater than normal
27. For the following, would you expect the pulse rate to be greater or less than the normal adult rate of 80 bpm?
A 90-year-old male�less than normal
28. What are the two gases exchanged through respiration?
Oxygen (O2 ) and carbon dioxide (CO2 ) are the two gases exchanged during respiration.
29. Which respiratory process involves the movement of air in and out of the lungs?
Pulmonary ventilation (or breathing) involves the movement of air into and out of the lungs.
30. What is external respiration?
External respiration is the exchange of oxygen (O2 ) and carbon dioxide (CO2 ) between blood in the pulmonary vessels and air in the alveoli.
31. What is the primary stimulus for breathing?
An increased carbon dioxide (CO2) level in the blood is the primary stimulus for breathing.
32. What mechanical forces allow the lungs to expand?
Lung expansion is allowed by the contraction and downward movement of the diaphragm and expansion of the thoracic space and may also include contraction of thoracic muscles and accessory muscles and movement of the abdomen, which also expand the thorax, lowering airway pressure and allowing air to move into the lungs.
33. How can you estimate a client's tidal volume?
Tidal volume can be estimated by observing the depth of the client's respirations.
34. What is the range of normal for an adult's respiratory rate?
A rate of 12 to 20 breaths per minute is normal for adults.
35. Besides the rate, what other characteristics of a client's respirations should you observe?
Depth, rhythm, effort, breath sounds, and chest movement should be observed in addition to rate.
36. What are some common clinical signs associated with poor oxygenation?
Pallor or cyanosis of the nails, lips, or skin; restlessness; apprehension; confusion; dizziness; fatigue; changes in pulse and blood pressure; and decreased level of consciousness are associated with poor oxygenation.
37. For a client whose BP is 150/80, what is the pulse pressure?
70 mm Hg. Is that normal? If so, explain. If not, what should the pulse pressure be? It is not normal; pulse pressure should not be more than one-third of 150, which is =50.
38. Which of the Korotkoff sounds would you record as the systolic pressure?
39. Which of the Korotkoff sounds would you record as the diastolic pressure?
40. A nurse is auscultating a BP. He hears the first sound at 170 mm Hg. The sound disappears immediately. At 150 mm Hg. the sound appears again and continues until there is silence at 80 mm Hg. The pressures were taken in the client's right arm while the client was lying down
How should the nurse record these pressures?
BP RA, supine, 170/80 with an auscultatory gap from 170 to 150. How do you explain what happened?
An auscultatory gap occurred. A gap is most commonly heard in hypertensive clients, whose systolic blood pressure is higher than the adult normal limit of 140 mm Hg.
41. Does the following patient have hypertension? 150/80 on two separate occasions
42. Does the following patient have hypertension? 180/100 on one occasion
43. Does the following patient have hypertension? 138/88 on two occasions
44. Does this client have primary hypertension? is obese and has a high sodium intake
45. Does this client have primary hypertension? is in renal failure
46. Does this client have primary hypertension? has hypertension induced by pregnancy
47. Does this client have primary hypertension? has a family history of hypertension
48. Define: Autonomic Nervous System.
Effects both pulse and blood pressure
49. Define: Hypothalmus.
50. Define: Hypertension.
Blood pressure greater than 120/80
51. Define: Apnea.
Absence of respirations
52. Defin: Bradycardia.
Pulse rate less than 60
53. Define: Tidal volume.
Amount of air moving in and out with each breath
54. Define: Dyspnea.
55. Define: Tachycardia
Pulse rate greater than 100
56. The amount of blood ejected from each ventricle with each heartbeat is which of the following? A. Pulse Pressure B. Cardiac output C. Stroke volume D. Tidal volume
C. Stroke volume - Rationale: Pulse pressure is the difference between the systolic and diastolic pressures. Cardiac output is the total quantity of blood pumped per minute. Tidal volume is amount of air moving in and out of the lungs with each breath.
57. False high blood pressure readings can be caused by which of the following? A. Lying in the supine position B. A blood pressure cuff that is too small C. A blood pressure cuff that is too large D. The arm positioned below the level of the heart
B. a blood pressure cuff that is too small - Rationale: A cuff that is too small may cause an inaccurately high blood pressure reading. Responses A, C and D can cause inaccurately low blood pressure readings.
58. A patient who has received an opioid analgesic will most likely exhibit which of the following vital sign changes? A. Tachycardia B. Bradycardia C. Increased blood pressure D. Decreased respiratory rate
D. Decreased respiratory rate - Rationale: Opioid analgesics typically decrease respiration, blood pressure, and heart rate, but not necessarily to less than 60 bpm (bradycardia).
59. Your patient just finished a cup of hot tea. How long will you wait before taking her temperature? A. 5 minutes B. 10 minute C. 15 minutes D. 20 minutes
C. 15 minutes
60. To assess a patient's blood pressure, the nurse will do which of the following? A. Use the diaphragm of the stethoscope B. Inflate the cuff to between 180 and 200 mmHg C. Inflate the cuff to 30 mmHg higher than the point he last palpated a pulse D. Talk to the patient in a calm, reassuring voice
C. Inflate the cuff to 30 mmHg higher than the point you last palpate a pulse - Rationale: This ensures an accurate reading. Response A is incorrect because you should use the bell of the stethoscope to best hear the patient's blood pressure. Response B is incorrect because the nurse should palpate the brachial pulse, then inflate the cuff to 30 mm Hg higher than she palpated; for some patients inflating to 180 mmHg would bee too high and would lead to an incorrect reading. Response D is incorrect because talking to the patient can interfere with your ability to hear the blood pressure.
61. Your patient is diagnosed with congestive heart failure. The pulse rate is thready, weak, and easily obliterated by light pressure. What is the quality of this pulse? A. 1+ B. 2+ C. 3+ D. 4+
A. 1+ - A quality of 1+ is a very weak pulse. Qualities of 2+ to 4+ indicate a progressively stronger pulse.
62. What is the normal respiratory rate for an adult? A. 30 to 40 breaths per minutes B. 20 to 30 breaths per minute C. 10 to 15 breaths per minute D. 12 to 20 breaths per minute