Chapter 29 Kozier And Erbs Fundamentals of Nursing 10th Edition by Berman Snyder

Chapter 29 Kozier And Erbs Fundamentals of Nursing 10th Edition by Berman Snyder

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

Question 1

Type: MCSA

An older client has an oral temperature reading of 97.2 degrees F. The nurse realizes that this client’s low temperature could be due to which observation?

1. The anxiety level of the client has increased.
2. Hormones have fluctuated in this client.
3. Muscle activity has increased during the client’s therapy session.
4. Loss of subcutaneous fat is noted.

Correct Answer: 4

Rationale 1: If a client is anxious or stressed, this response stimulates the sympathetic nervous system. This in turn increases the production of epinephrine and norepinephrine, which increases metabolic and heat production, causing the temperature to rise.

Rationale 2: Women experience more hormonal fluctuations than men, and this is usually true with the secretion of progesterone at the time of ovulation. Because this client is older, hormone fluctuations and ovulation will not impact the temperature.

Rationale 3: Exercise, which represents hard work or strenuous activity, increases body temperature. That is not the case with this client. No reference has been made to a therapy session, and the temperature is decreased.

Rationale 4: This client is older and research shows that older people are at risk for hypothermia. When one ages, subcutaneous fat is lost.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1.  Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 2. Identify the variations in normal body temperature, pulse, respirations, and blood pressure that occur from infancy to old age.

MNL Learning Outcome: 3.3.1. Explain the body’s regulation of temperature, pulse, respirations, and blood pressure.

Page Number: 479

 

Question 2

Type: MCSA

The nurse is preparing to measure a client’s temperature. What is the first thing that the nurse should do to ensure an accurate temperature reading?

1. Assess that the equipment used is working properly.
2. Place the client in a position that is most comfortable for the health care provider.
3. Take the temperature with a chemical disposable thermometer when the client is perspiring.
4. Wait at least 10 minutes before taking the temperature after a client has been smoking.

Correct Answer: 1

Rationale 1: If the equipment is not working properly, no accuracy will be obtained in the readings.

Rationale 2: The type of equipment or method that is chosen will dictate client position, not the position of the health care provider.

Rationale 3: If the equipment is not working properly, no accuracy will be obtained in the readings. The type of equipment or method that is chosen will dictate client position, not the position of the health care provider. In order to use a chemical disposable thermometer, the client’s skin must be dry for the thermometer to adhere to the skin.

Rationale 4: The recommended time to wait to assess an oral temperature is 30 minutes after one smokes, not 10 minutes.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1.  Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Verbalize the steps used in: a. Assessing body temperature.

MNL Learning Outcome: 3.3.1. Explain the body’s regulation of temperature, pulse, respirations, and blood pressure.

Page Number: 484

 

Question 3

Type: MCSA

The nurse needs to measure the temperature of a client who has a history of heart disease and has eaten a bowl of vegetable soup 45 minutes ago. Which site should the nurse use?

1. Axilla
2. Oral
3. Popliteal
4. Rectal

Correct Answer: 2

Rationale 1: The axilla is the preferred site for newborns, not adults.

Rationale 2: Body temperature is frequently measured orally even if the client has eaten or drank something cold or hot. One only needs to wait 30 minutes, and then this site can be used.

Rationale 3: The popliteal site would not be used given the history of heart disease. There could be circulatory issues that might affect accurate reading because this site is much farther away from the heart.

Rationale 4: The rectal site would be contraindicated in this client given the history of heart disease. With the diagnosis of heart disease, the nurse would need to assess for the presence of hemorrhoids.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1.  Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Verbalize the steps used in: a. Assessing body temperature.

MNL Learning Outcome: 3.3.3. Apply the principles of assessing vital signs in the care of a client.

Page Number: 482

 

Question 4

Type: MCSA

While waiting for the physician to respond regarding a client’s elevated temperature, what can the nurse do to assist the client?

1. Bathe the client with ice water.
2. Give the client an antipyretic.
3. Increase fluid intake.
4. Lower the room temperature.

Correct Answer: 3

Rationale 1: Bathing the client in ice water would lower the client’s temperature too fast, possibly causing hypothermia.

Rationale 2: Giving a client an antipyretic requires a doctor’s order.

Rationale 3: Elevated body temperature contributes to dehydration, which leads to body tissues drying out and malfunctioning. Rehydrating the client’s tissues will allow the temperature to return to normal.

Rationale 4: Dropping the temperature of the room would lower the client’s temperature too fast, possibly causing hypothermia.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1.  Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implemenation

Learning Outcome: 4. Describe appropriate nursing care for alterations in vital signs.

MNL Learning Outcome: 3.3.4. Compare expected and unexpected outcomes.

Page Number: 481