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Cardiorespiratory response when core body temperature falls into the range of 89ºF to 92ºF (31.7ºC to 33.3ºC) involves __________ .
respirations and pulses slow.
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A patient with a core body temperature of 95°F (35°C) will MOST likely experience:
11. Pale skin in a child indicates that the: A. child is in severe decompensated shock. B. oxygen content in the blood is decreased. C. blood vessels near the skin are constricted. D. child’s core body temperature is elevated.
Answer: C Question Type: General Knowledge Page: 1155
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Which vital sign change in a client with hypovolemic shock indicates to the nurse that the therapy is effective? A. Urine output increase from 5 mL/hr to 25 mL/hr B. Pulse pressure decrease from 35 mm Hg to 28 mm Hg C. Respiratory rate increase from 22 breaths/min to 26 breaths/min D. Core body temperature increase from 98.2 F (36.8 C) to 98.8 F (37.1 C)
ANS: A Rationale: During shock, the kidneys and baroreceptors sense an ongoing decrease in MAP and trigger the release of renin, antidiuretic hormone (ADH), aldosterone, epinephrine, and norepinephrine to start kidney compensation, which is very sensitive to changes in fluid volume. Renin, secreted by the kidney, causes decreased urine output. ADH increases water reabsorption in the kidney, further reducing urine output. These actions compensate for shock by attempting to prevent further fluid loss. This response is so sensitive that urine output is a very good indicator of fluid resuscitation adequacy. If the therapy is not effective, urine output does not increase.
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The Celsius core body temperature of an average, healthy human is nearest to A. 100 degrees B. 68 degrees C. 37 degrees D. 20 degrees
2 Rectal temperature recording provides the most accurate core body temperature measure for infants from birth to 2 years of age. Thus, the nurse should use the rectal temperature measurement for the infant. The infant would not be able to hold the thermometer under the tongue. and thus oral measurement should not be used for a 3-month-old infant. Axillary temperature recording is the most convenient temperature recording method in infants. However, it does not give an accurate temperature reading. Tympanic method of temperature recording is not suitable for children younger than 2 years of age because it can damage the tympanic membrane of the ear.
Which type of temperature recording should a nurse use for an accurate temperature reading on a 3-month-old infant? 1 Oral 2 Rectal 3 Axillary 4 Tympanic
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Your assessment of a 23-year-old female reveals a core body temperature of 93.4°F (34°C). She is conscious, answers your questions appropriately, is shivering, and complains of nausea. Her skin is cold and pale, her muscles appear rigid, and her respirations are rapid. You should:
place heat packs to her groin, axillae, and behind her neck; cover her with warm blankets; and avoid rough handling.
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