Patho: Ch 14

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

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?

"Get a Zostavax vaccination."

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 the point at which a stimulus is perceived as painful."

A nurse conducting a community education program on hypothermia includes which of the following as a risk factor?

Alcohol

When giving pain medicine for acute pain, health care workers are reluctant to provide much-needed opioid pain medicine. What is the major concern of health care workers when providing opioid pain relief?

Fear of addiction

The loss of heat from the body through the circulation of air currents is known as:

Convection

The provider is testing the client's ability to identify the specific location of skin touch in two different areas. This ability is communicated through which pathway?

Discriminative

The parents of a premature newborn infant ask why their child needs to remain under a warming light. On what information does the nurse base the answer?

Full-term newborns have brown fat, which is used to generate heat.

Which is a major excitatory neurotransmitter released from the central nerve endings of the nociceptive neurons?

Glutamate

A nurse is providing care for a 44-year-old male client who is admitted with a diagnosis of fever of unknown origin (FUO). Which characteristic of the client's history is most likely to have a bearing on his current diagnosis?

HIV positive and homeless

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?

Heatstroke

A client's temperature readings are as follows: 99.6°F (37.5°C) at 4 pm; 102°F (38.9°C) at 8 pm; and 97.9°F (36.6°C) at 12 am. The nurse's hand-off should include which note?

Intermittent fever

A client reports a sudden intense headache. Which factor would indicate the presence of a possible subarachnoid hemorrhage?

Intractable pain

What will conduct injurious stimuli to alert the body to potential damage?

Nociceptors

When testing nociceptive stimuli to elicit a withdrawal reflex in the body, what stimuli are commonly used?

Pressure from a sharp object

The nurse needs to assess a 1-year-old child for fever. Which approach will produce the most accurate reading?

Rectal

A client is experiencing chest pain that radiates to the left arm and neck. The nurse would interpret this pain as:

Referred

Which skin receptors communicate the sensation of heavy and continuous touch and pressure?

Ruffini end-organs

A client who is being treated for chronic low back pain is using a TENS unit for relief of pain. The nurse is aware that the use of this device is considered what type of pain relief?

Stimulus-induced analgesia

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:

Visual disturbances

The nurse is taking the history of a client scheduled for surgery with general anesthesia. What is the best response by the nurse to the client's statement that an uncle died after receiving general anesthesia?

Inform the anesthesiologist.

Why does subcutaneous fat affect the body's ability to insulate itself? Select all that apply.

It adds thickness to the body's outer shell Its poor ability to conduct body heat

A client in the intensive care unit has been having rapidly changing core body temperatures that requires close monitoring. The client is intubated and has a pulmonary artery catheter and a Foley catheter. The nurse should obtain and/or record the temperature from which of the following?

Pulmonary artery catheter

The nurse asks the client if she would like medication for pain after an appendectomy but the client decides to wait. What does the nurse understand may influence this client's pain threshold and tolerance? Select all that apply.

Psychological factors Cultural factors Environmental factors Familial factors