Patho Ch 14
A child age 33 days is presented to the emergency department of a hospital by her parents following a 2-day fever. Her temperature is 38°C (100.4°F) tympanically. Which diagnostic test is most clearly indicated? Computed tomography (CT) of the head Urine for culture and sensitivity Abdominal ultrasound Electrolytes, blood urea nitrogen (BUN), and creatinine levels.
Urine for culture and sensitivity Explanation: Infants with a fever are at risk of urinary tract infections, which would be diagnosed through a urine test for culture and sensitivity. Electrolytes, BUN and creatinine, CT of the head, and abdominal ultrasound are not as closely associated with differential diagnosis of the child's fever.
An older adult tells the nurse, "My friend just developed shingles and has a lot of pain. Is there a way for me to protect myself from it?" Which of the following is an appropriate response from the nurse? "Use antiviral drugs as soon as you are exposed." "Avoid children and people with shingles." "Apply a topical anesthetic agent." "Get a Zostavax vaccination."
"Get a Zostavax vaccination." Explanation: Herpes zoster is the viral infection caused by the varicella zoster virus. The first infection is called chickenpox. When there is a recurrence it is called shingles. The virus is believed to remain dormant in the nerve root until the client has a decline in cellular immunity when the virus will replicate. The pain is often described as throbbing, burning, or stabbing. The best prevention is a vaccine for adults age 60 and older. Antivirals will lessen the severity at the time but will not prevent infection.
A client asks if pain threshold and pain tolerance are the same. The best response by the health care provider would be: "Pain threshold is not varied from person to person." "Pain tolerance is not affected by psychological, familial, cultural, and environmental factors." "Pain tolerance is the minimum intensity of pain a client will endure." "Pain threshold is the point at which a stimulus is perceived as painful."
"Pain threshold is the point at which a stimulus is perceived as painful." Explanation: Pain threshold is closely associated with the point at which a nociceptive stimulus is perceived as painful. Pain tolerance relates more to the total pain experience; it is defined as the maximum intensity or duration of pain that a person is willing to endure before the he or she wants something done about the pain. Psychological, familial, cultural, and environmental factors significantly influence the amount of pain a person is willing to tolerate. The threshold for pain is fairly uniform from one person to another, whereas pain tolerance is extremely variable.
Infants are at greater risk of hypothermia than children because of which of the following? An increased thickness of subcutaneous fat at birth Their inability to remove clothing A high ratio of surface area to body mass The inability of infants to state that they are cold
A high ratio of surface area to body mass Explanation: Relative to body weight, the body surface of an infant is three times that of an adult and in low-birth-weight infants, the insulating layer of subcutaneous fat is thinner. The inability to communicate their needs or remove clothing is not a primary risk for hypothermia.
The nurse is caring for a team of clients with febrile illnesses. For which medication prescription would the nurse seek clarification? Acetaminophen 650 mg po every 4 hours for a 27-year-old with viral meningitis Naproxen 500 mg every 12 hours for a 63-year-old with rheumatoid arthritis Ibuprofen 600 mg po every 6 hours for a 48-year-old with pneumonia Aspirin 650 mg every 4 hours for a 15-year-old with influenza
Aspirin 650 mg every 4 hours for a 15-year-old with influenza Explanation: Antipyretic agents such as aspirin, acetaminophen, naproxen, and ibuprofen are commonly used to relieve pain and fever. Reye syndrome is a serious complication of administering aspirin products to children with viral illnesses such as chickenpox or influenza.
The nurse on the pediatric unit is implementing distraction strategies for a child who is experiencing pain. Which strategies would be best for the nurse to implement? Select all that apply. Bubbles Music Acetaminophen Television Silence Games
Bubbles Music Television Games Explanation: Distraction helps children of any age divert their attention away from pain and onto other activities. Common diversions include bubbles, music, television, conversation, and games.
What will the nurse teach a client with trigeminal neuralgia about the condition? Carbamazepine is a first-line treatment. Surgery will relieve the condition. It is good to spend time alone every day. Avoid eating if it triggers the pain.
Carbamazepine is a first-line treatment. Explanation: Trigeminal neuralgia is a condition in which clients experience brief, severe, repetitive lightninglike or throbbing pain along the distribution of one or more of the branches of the fifth cranial nerve. Clients should be taught to avoid triggers when possible, but although eating may be a trigger, it is necessary for the client to maintain nutrition. Social isolation is a possible problem arising from the condition. Time alone does not contribute significantly to improvement of the condition. Although treatment rarely provides total relief, trigeminal neuralgia can be controlled with carbamazepine and surgical release of vessels, nerve roots, or scar tissue. If other treatments are ineffective, partial destruction of the nerve branches with heat, balloon compression, or glycerol injection may be performed. Newer therapies to be considered are botulinum toxin injection and gamma radiation with stereotactic surgery.
A nurse assessing an older adult for signs and symptoms of infection in the absence of a fever should assess for which of the following? Select all that apply. Weight gain Depression Decreased mental status Change in fuctional capacity Fatigue
Decreased mental status Change in fuctional capacity Fatigue Explanation: Signs and symptoms of infection in an older adult in the absence of a fever include decreases in mental status and functional capacity, fatigue, weight loss, and weakness.
An 80-year-old woman is undergoing total hip replacement surgery as treatment for severe osteoarthritis. During the procedure, the client's core temperature falls to 31.6°C (88.9°F), necessitating interventions to address her hypothermia. The surgical team recognizes that there are likely multiple causes of the client's hypothermia. Which factor would the team be mostjustified in ruling out as a contributor? Decreased temperature adaptation due to her unconscious state The cold environment in most operating theaters Decreased vasoconstriction as a result of anesthetic Impaired thermoregulatory mechanisms due to anesthetic
Decreased temperature adaptation due to her unconscious state Explanation: Unconsciousness in and of itself is not an identified contributor to surgical hypothermia. The cold environment, decreased vasoconstriction, and impaired thermoregulation resulting from anesthetic are all potential contributors.
A client has an increase in core body temperature. What assessment finding does the nurse expect? Decreased urination Blue nail beds Decreased skin temperature Flushed skin
Flushed skin Explanation: The client with an increase in their core temperature will be accompanied by flushed, warm skin as the body tries to lower the temperature. The other assessments do not correlate with increased core temperature.
A nurse is planning care for a client coming into the emergency department via ambulance on a hot summer day with the following symptoms: temperature of 105°F (40.5°C), absence of sweating, and loss of consciousness. The nurse anticipates that the client has which condition? Heat exhaustion Blunted febrile response Hyperthermia Heatstroke
Heatstroke Explanation: Symptoms of heatstroke include a body temperature greater than 104°F (40°F), absence of sweating, and central nervous system abnormalities such as delirium, convulsions, and loss of consciousness.
A client has been diagnosed with osteomyelitis and admitted to the hospital. The client's fever persists throughout most of the day but returns to normal at least twice a day. Which pattern of fever is this client displaying? Intermittent Relapsing Erratic Remittent
Intermittent Explanation: Intermittent fever patterns are very changeable, but they do return to normal at least once every 24 hours. A remitting fever pattern temperature does not return to normal and varies a few degrees in either direction. In a sustained fever pattern, the temperature remains above normal with minimal variations. A relapsing fever is one in which there is one or more episodes of fever, each as long as several days, with 1 or more days of normal temperature between episodes.
The nurse instructs the unlicensed assistive personnel (UAP) to be sure to turn the client every 2 hours in order to avoid pressure on the skin and avoid a pressure ulcer. What type of stimuli is the nurse encouraging the UAP to avoid? Thermal stimuli Mechanical stimuli Chemical stimuli Pain stimuli
Mechanical stimuli Explanation: Mechanical stimuli can arise from intense pressure applied to skin or from the violent contraction or extreme stretch of a muscle. Chemical stimuli arise from a number of sources, including tissue trauma, ischemia, and inflammation. Thermal stimuli can result from extremes of heat or cold. Pain stimuli is not a stimuli.
A client has a fever that was induced by damage to the hypothalamus due to intercranial bleeding. The nurse plans care for which type of fever? Exogenous Systemic Neurogenic Intrinsic
Neurogenic Explanation: Neurogenic fever has its origin in the central nervous system and is usually caused by damage to the hypothalamus from trauma, intercranial bleeding, or increased intercranial pressure. The nurse should plan care for a client with a neurogenic fever.
A client experiencing phantom limb pain after a traumatic amputation finds that opioids, biofeedback, a transcutaneous electrical nerve stimulation unit, and relaxation therapy are all needed to reduce the pain to a tolerable level. Which pain theory is best supported by this event? Neuromatrix Pattern Gate control Specificity
Neuromatrix Explanation: The neuromatrix theory joins multiple sources of input to aid in understanding the multiple dimensions of pain experience and behavior in chronic pain, along with other complex pain phenomena such as phantom limb pain. The gate control theory proposes that you can block pain by sending a different signal such as cold or pressure that will close a gate in the spinal cord to prevent transmission of the pain signal. The specificity theory states that pain is experienced when specific sensors are stimulated. The pattern theory is a collection of theories proposing that not only do pain receptors share pathways with other senses but that different activity patterns indicate whether pain is present or not.
What will conduct injurious stimuli to alert the body to potential damage? Odorant Proprioceptors Nociceptors Thermoreceptors
Nociceptors Explanation: Nociceptors are sensitive to painful and noxious stimuli and alert the system to injury. Thermoreceptors will perceive heat, proprioceptors will perceive body position, and odorant receptors will perceive the sensation of smell.
A two-day postoperative client's temperature was 98.5°F (36.9°C) at 3:00 pm. At 6:00 pm, the unlicensed assistant (UAP) notifies the nurse that the client's temperature is 102°F (38.9°C). Which action should the nurse take? Document the temperature. Offer the client a cold drink. Notify the physican. Increase intravenous fluid rate.
Notify the physican. Explanation: The nurse should contact the physician, as the increase in the client's temperature is outside of the normal range and/or the normal diurnal variation in temperature.
The route considered the most accurate to measure a core body temperature is: Thermodilutional (pulmonary artery) Rectal Esophageal Thermosensoral (bladder)
Rectal Explanation: The rectal temperature is used as a measure of core temperature and is least invasive of all of these options.
The nurse is conducting a community education course on hyperthermia and heatstroke. The nurse determines that the participants understand the information when they state that which bodily function increases core temperature? Bradycardia Vasodilation Shivering Sweating
Shivering Explanation: Shivering and vasoconstriction can increase core body temperature, whereas vasodilation and sweating can decrease core body temperature.
A client with pneumonia is admitted with these vital signs: temperature 99.7ºF (37.6°F), pulse 80 beats/min, respirations 18/minute, and BP 120/80 mm Hg. Which set of vital signs does the nurse anticipate when the client begins to shiver and requests another blanket several hours later? T 100.9ºF (38.3°C), P 90/min, R 20/min, BP 126/80 mm Hg T 98.4ºF (36.9°C), P 82/min, R 16/min, BP 106/70 mm Hg T 99.7ºF (37.6°C), P 86/min, R 18/min, BP 130/82 mm Hg T 97.2ºF (36.2°C), P 70/min, R 12/min, BP 114/60 mmHg
T 100.9ºF (38.3°C), P 90/min, R 20/min, BP 126/80 mm Hg Explanation: During the chill phase of fever, the client feels cold and may experience pale skin with goosebumps, but the temperature is rising. When the body reaches the new set point, shivering will stop, and flushing will begin.
A client is experiencing anorexia, myalgia, arthralgia, headache, and fatigue. The nurse should assess for: Temperature Respirations Urinary output Hypothermia
Temperature Explanation: Common clinical manifestations of fever include anorexia, myalgia, arthralgia, headaches, and fatigue; thus, the nurse should assess the client's temperature.
The nurse learns that different types of headaches respond to different therapies. Which headache is most responsive to nonpharmacologic therapy? Cluster Migraine Tension Sinus
Tension Explanation: Tension-type headaches often are more responsive to nonpharmacologic techniques, such as biofeedback, massage, acupuncture, relaxation, imagery, and physical therapy, than other types of headache. For people with poor posture, a combination of range-of-motion exercises, relaxation, and posture improvement may be helpful. The other options are usually best treated with medications that focus on the cause of the pain.
In addition to medication efficacy, what should the nurse consider when assessing the appropriateness of a pain medication prescribed to an older adult client? Select all that apply. The availability of nonpharmacologic therapies The cost of the medication The possibility of drug interaction The existence of chronic illnesses The effects of normal aging on metabolism
The possibility of drug interaction The effects of normal aging on metabolism The existence of chronic illnesses The cost of the medication Explanation: Although efficacy is important when considering the use of pharmacologic agents for pain relief in the older adult population, cost and safety must also be considered. Safety issues that must be considered among older adults include changes in drug metabolism, other disease comorbidity, and polypharmacy. Nonpharmacologic therapies are often used in addition to medications.
A client comes to the clinic for evaluation of a sharp, intermittent, severe, stabbing facial pain that she describes as "like an electric shock." The pain occurs on only one side of her face. It seems to be triggered when she chews, brushes her teeth, or sometimes when she merely touches her face. Often it is accompanied by involuntary grimacing. What diagnosis is most likely? Postherpetic neuralgia Trigeminal neuralgia Migraine headache Complex regional pain syndrome
Trigeminal neuralgia Explanation: Her symptoms are characteristic of trigeminal neuralgia, caused by damage to cranial nerve V, which carries impulses of touch, pain, pressure, and temperature to the brain from the face and jaw. Postherpetic neuralgia is a complication of shingles. Migraine headache symptoms feel as if they occur in one or more regions of the head, not the face. Complex regional pain syndrome affects either one arm or leg.
A recovery room nurse monitoring a client for adverse effects of cold cardiplegia assesses for: Postoperative anxiety Increased intercranial pressure Ventricular dysrhythmia Postoperative migraine
Ventricular dysrhythmia Explanation: The nurse should assess for ventricular dysrhythmia, decreased cerebral blood flow, and postoperative myocardial depression.
A client with a history of migraine headaches tells the physician that he or she usually experiences an aura before the onset of the headache. The client is most likely experiencing: Lethargy Dysphasia Dizziness Visual disturbances
Visual disturbances Explanation: Migraine aura is associated with visual symptoms, including flickering lights, spots, or loss of vision; sensory symptoms, including feeling of pins or needles, or numbness; and speech disturbances or other neurologic symptoms.
A surgical client is at greatest risk for hypothermia during a surgical procedure related to: the decreased temperature of the surgical suite caused by electrical appliances. impaired thermoregulatory mechanisms brought on by anesthesia. the instillation of warmed intravenous fluids that lower the core temperature. negligence of the anesthesiologist in regulating the body temperature.
impaired thermoregulatory mechanisms brought on by anesthesia. Explanation: A surgical client has a higher risk of hypothermia related to impaired thermoregulatory mechanisms brought on by anesthesia and other drugs. The instillation of warmed intravenous fluids is used to increase the core temperature, not lower it. The remaining options related to room temperature and the regulation of body temperature are not relevant.
A client is experiencing a cluster headache. The client would most likely manifest: severe pain behind the eye. nausea with vomiting. symptoms aggravated by physical activity. sensitivity to light.
severe pain behind the eye. Explanation: Symptoms of cluster headache include severe, unrelenting unilateral pain located in the orbital area. The pain radiates behind the eye to the ipsilateral trigeminal nerve. The client may also experience symptoms such as restlessness or agitation, conjunctival redness, lacrimation, nasal congestion, rhinorrhea, forehead and facial sweating, miosis, ptosis, and eyelid edema. The other options are associated with migraine headache.
A client has been diagnosed with a fever of unknown cause. The nurse recognizes this as: A fever of new onset A fever that only occurs in adults A fever that has responded well to several medications A prolonged fever that does not have an identified source
A prolonged fever that does not have an identified source Explanation: A prolonged fever for which the cause is difficult to ascertain is often referred to as fever of unknown origin (FUO). FUO is defined as a temperature elevation of 38.3°C (101°F) or higher that is present for 3 weeks or longer. An FUO can occur in children or adults.
What is the most common cause of drug fever? Increased heat production from PTU Serotonin syndrome Impaired peripheral heat dissipation by atropine Hypersensitivity reaction to medication
Hypersensitivity reaction to medication Explanation: The most common cause of drug fever is a hypersensitivity reaction. Drug fever can also be caused by the antithyroid medication propylthiouracil (PTU), atropine and anticholinergic medications, antipsychotic agents, tricyclic antidepressants, cocaine, and amphetamines. The agitation, hyperthermia, and hyperactivity of serotonin syndrome occur with overdose of serotonin reuptake inhibitors.
A client on an acute medicine unit with a diagnosis of small bowel obstruction is reporting intense, diffuse abdominal pain. Which physiologic phenomenon is most likely contributing to the client's pain? Nociceptive afferents are conducting along the cranial and spinal nerve pathways of the ANS. First-order neurons are inappropriately signaling pain to the dorsal root ganglion. An overlap of nerve fiber distribution between the dermatomes is causing the pain. The client is experiencing neuropathic pain.
Nociceptive afferents are conducting along the cranial and spinal nerve pathways of the ANS. Explanation: Visceral pain, as characterized by the client's description of her pain, is conducted by way of nociceptive afferents that use the cranial and spinal nerve pathways of the ANS. The problem is not likely rooted in the inappropriate firing of first order neurons or the substitution of conduction by C fibers. Pain that is attributable to a pathologic process apart from the neural pain network is not normally considered to be neuropathic. An overlap of nerve fiber distribution between the dermatomes occurs with cutaneous pain, not visceral pain.
A nurse assesses a client with a cerebral infarct for sensation. Which result indicates that second-order neurons are intact? Patellar reflex +2 Alert and oriented x3 Flaccid hemiparesis Dysphagia
Patellar reflex +2 Explanation: First-order neurons transmit sensory information from the periphery of the neurons to the central nervous system. Second-order neurons communicate directly with the thalamus and work with the reflex networks and sensory pathways in the spinal cord. Third-order neurons relay information from the thalamus to the cerebral cortex. Level of consciousness does not indicate sensation.
Which client is exhibiting headache symptoms that indicate a need for further evaluation? Parent with general head pain after a night caring for an ill child Older adult with a headache after missing the evening meal Pregnant mother with drowsiness and unrelenting headache College student with unilateral headache after eating a chocolate bar
Pregnant mother with drowsiness and unrelenting headache Explanation: Primary headaches such as migraine, tension headache, cluster headache, and chronic daily headache do not require additional evaluation. Clients with secondary headaches should receive further evaluation. Possible causes of secondary headaches are cerebral hemorrhage or aneurysm, meningitis, cancer, and nerve lesions. Additionally, clients requiring further evaluation include those with sudden onset or progression of headaches, someone who is immunosuppressed, or a woman who is pregnant.
Place the four successive stages of fever in correct order. 4Prodromal 3Chill 1Flush 2Defervescence
Prodromal Chill Flush Defervescence Explanation: The physiologic behaviors that occur during the development of fever can be divided into four successive stages: a prodrome; a chill, during which the temperature rises; a flush; and a defervescence.
A client has a mild headache and fatigue. He also states he has some aches and pains. Which stage of fever does the nurse determine the client is experiencing? Chill Flush Prodrome Defervescence
Prodrome Explanation: During the first or prodromal period there are nonspecific complaints such as mild headache and fatigue, general malaise, and fleeting aches and pains.
Which clients are showing manifestations of infection? Select all that apply. A 50-year-old, temperature 36.2°C (97.3°F), heart rate 65 beats/min, muscle aches A 2-month-old, temperature 38.3°C (100.4°F), lethargy, poor feeding, and cyanosis A 75-year-old, temperature 37.3°C (99.2°F), declining mental status, weakness and fatigue A 25-year-old, temperature 40°C (104°F), sweating, shivering, states generalized pain A 5-year-old, temperature 36.8°C (98.2°F), talkative, actively engaged in playing
A 75-year-old, temperature 37.3°C (99.2°F), declining mental status, weakness and fatigue A 25-year-old, temperature 40°C (104°F), sweating, shivering, states generalized pain A 2-month-old, temperature 38.3°C (100.4°F), lethargy, poor feeding, and cyanosis Explanation: An older adult with an infection may have a minimal rise in temperature, but exhibit changes in mental status, weakness, fatigue, and weight loss. An infant younger than three months may have a relatively mild fever, but a serious infection. An adult with a high fever will exhibit sweating and chills. Aches and pains may occur with shivering and the infectious illness. A client with a temperature within the normal range, exhibiting no other signs of change, is not considered to have an infection.
What will the nurse teach a client with trigeminal neuralgia about the condition? Surgery will relieve the condition. It is good to spend time alone every day. Avoid eating if it triggers the pain. Carbamazepine is a first-line treatment.
Carbamazepine is a first-line treatment. Explanation: Trigeminal neuralgia is a condition in which clients experience brief, severe, repetitive lightninglike or throbbing pain along the distribution of one or more of the branches of the fifth cranial nerve. Clients should be taught to avoid triggers when possible, but although eating may be a trigger, it is necessary for the client to maintain nutrition. Social isolation is a possible problem arising from the condition. Time alone does not contribute significantly to improvement of the condition. Although treatment rarely provides total relief, trigeminal neuralgia can be controlled with carbamazepine and surgical release of vessels, nerve roots, or scar tissue. If other treatments are ineffective, partial destruction of the nerve branches with heat, balloon compression, or glycerol injection may be performed. Newer therapies to be considered are botulinum toxin injection and gamma radiation with stereotactic surgery.
In describing the ideal analgesic, what factors would be included? Select all that apply. Effective Have minimal adverse effects Decrease the level of consciousness Inexpensive Addictive
Inexpensive Have minimal adverse effects Effective Explanation: The ideal analgesic would be effective, nonaddictive, and inexpensive. In addition, it would produce minimal adverse effects and not affect the person's level of consciousness.
A client is experiencing chest pain that radiates to the left arm and neck. The nurse would interpret this pain as: Cutaneous Referred Somatic Visceral
Referred Explanation: Referred pain is pain that is perceived at a site different from its point of origin but innervated by the same spinal segment. Visceral pain originates in the visceral organs and is one of the most common pains produced by disease. Cutaneous pain arises from superficial structures. Somatic pain originates in deep body structures.
Antipyretic drugs, such as aspirin, ibuprofen, and acetaminophen, are often used to alleviate the discomforts of fever and protect vulnerable organs, such as the brain, from extreme elevations in body temperature. The use of aspirin is limited in children, however, because it can sometimes cause which disease? Münchausen syndrome Reye syndrome Angelman syndrome Guillain-Barré syndrome
Reye syndrome Explanation: Aspirin can cause Reyé syndrome in children; therefore, the Centers for Disease Control and Prevention, US Food and Drug Administration, and American Academy of Pediatrics Committee on Infectious Diseases advise against the use of aspirin and other salicylates in children with influenza or chickenpox. Münchausen syndrome is an unusual psychiatric condition characterized by habitual pleas for treatment and hospitalization for a symptomatic but imaginary acute illness. Guillain-Barré syndrome is an idiopathic, peripheral polyneuritis that occurs 1 to 3 weeks after a mild episode of fever associated with a viral infection or with immunization. Angelman syndrome is an autosomal recessive syndrome characterized by jerky puppet-like movements, frequent laughter, intellectual disability, motor retardation, a peculiar open-mouthed facial expression, and seizures.