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 A
Explanation
A. Body temperature follows a circadian rhythm, typically being lowest in the early morning (around 4–6 AM) and peaking in the late afternoon or evening.
B. Stress activates the sympathetic nervous system, which increases metabolic activity and raises body temperature rather than lowering it.
C. Physical activity generates heat, leading to an increase in body temperature, not a decrease.
D. While some surgical preparations involve cooling the patient, body temperature is not naturally lower before surgery. Instead, preoperative anxiety may even cause a slight increase in temperature.
Correct Answer is A
Explanation
A. Falsely low. Using an adult-sized cuff on a child results in an overestimation of the cuff size, causing the cuff to not inflate properly and distribute less pressure, leading to a falsely low blood pressure reading.
B. Indistinct. The reading may be inaccurate, but it will still produce a numerical value rather than being completely indistinct.
C. Accurate. Accuracy depends on using a cuff size appropriate for the child's arm circumference. An adult cuff on a child is too large, leading to an incorrect reading.
D. Falsely high. A too-small cuff would produce a falsely high reading, but an oversized cuff produces a falsely low blood pressure.
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