Ch 14: Somatosensory Function, Pain, Headache, & Temperature Regulation

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."

The nurse knows that chronic pain lacks which of the characteristic pain-related reactions?

Increased heart rate

A febrile, 3-week-old infant is currently undergoing a diagnostic workup to determine the cause of the fever. Which statement conveys the rationale for this careful examination?

Infants are susceptible to serious infections, because of their decreased immune function.

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?

Neurogenic

The nurse working in the delivery department knows that which factor is a primary risk for the newborn to develop hypothermia?

Newborns have a high ratio of surface area to body mass.

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

Nociceptors

A surgical client is at greatest risk for hypothermia during a surgical procedure related to:

impaired thermoregulatory mechanisms brought on by anesthesia.

What can the nurse tell a client about antipyretic drugs during fever?

"Antipyretics help to protect the body."

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?" How should the nurse respond?

"Ask your healthcare provider about a herpes zoster vaccine."

The nurse is teaching a client about various methods of pain control. Which information will the nurse include when teaching the client about applying heat for pain control?

"Heat promotes more blood flow to the area to improve oxygen supply."

The nurse is working with a client who has been diagnosed with recurring migraine headaches. Which advice by the nurse is most appropriate?

"Many people find that maintaining regular eating and sleeping habits is beneficial."

A nurse assessing an older adult 3 hours postoperative notes guarding, grimacing, and stiff body movement when changing positions. The client denies feeling pain. Which response will help the nurse best manage this client's pain?

"You seem to be uncomfortable. Pain is common with surgery. I can bring you pain medication."

A client who has been exercising says to the nurse, "My skin is so hot!" What is the nurse's best response?

"Your body is trying to lower your temperature."

Which client will the nurse be assessing in relation to problems with thermoregulation?

66-year-old client with damage to the hypothalamus secondary to a cerebral vascular accident.

Which symptom indicates the next stage of a fever after a prodrome?

A chill

Infants are at greater risk of hypothermia than children because of which of the following?

A high ratio of surface area to body mass

Which client may be experiencing the effects of neuropathic pain?

A man with pain secondary to his poorly controlled diabetes

A client has been diagnosed with a fever of unknown cause. The nurse recognizes this as:

A prolonged fever that does not have an identified source

The nurse is caring for a client who has returned from surgery after having a colon resection. What is the best method for the nurse to use when administering an opioid for pain in order to optimize pain control?

Administer the opioid preemptively and before pain becomes extreme.

A client reports general malaise and has a temperature is 103.8°F (39.9°C). What is the rationale for administering a prescribed aspirin, an antipyretic, to this client?

Antipyretics protect vulnerable organs, such as the brain, from extreme temperature elevation.

When conducting a health assessment that focuses on the pain experienced by an older client diagnosed with early dementia, the nurse will pay particular attention to which of the following?

Behavioral signs of pain demonstrated by the client

Nonshivering thermogenesis occurs in which of the following to help the newborn infant fight hypothermia?

Brown fat

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

Convection

Which type of thermometer is the best to use in determining an accurate temperature during an episode of hypothermia?

Electrical thermistor

An older adult's blood cultures have come back positive, despite the fact that the client's oral temperature remains within normal range. Which phenomena underlies the alterations in fever response that occur in older adults?

Disturbance in the functioning of the thermoregulatory center

What is the most common cause of drug fever?

Hypersensitivity reaction to medication

In assessing a client with a cerebral infarct for sensation, which results would a nurse find that would indicate that third-order neurons are intact?

Identifying a scent

With which activity would a client experiencing astereognosis need help?

Identifying an object by touch

A normal response to fever is an elevated heart rate. A client with a fever who is not exhibiting an elevated heart rate would indicate to the nurse that the cause of the fever might be:

Legionnaires' disease

Which intervention is usually the first line of therapy when treating moderate pain in the older adult population?

Nonopioids such as acetaminophen

Which client is exhibiting headache symptoms that indicate a need for further evaluation?

Pregnant mother with drowsiness and unrelenting headache

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?

Prodrome

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

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?

Reye syndrome

A client presents with a temperature of 38.8°C (101.8°F), a racing heart, fatigue, and an upset stomach after working outside in a hot day. Which assessment findings suggest fever rather than hyperthermia as a cause of the elevation in the man's temperature? Select all that apply.

Shivering Pallor

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

About 30 minutes following the morning medication pass, the nurse's aide informs the nurse that one of the clients on their team is complaining of "hot sweats." The aide also states that the client's temperature is now 101.5°F (38.6°F). Knowing that some medications can cause hyperthermia, the nurse reviews the medications. Which client is at high risk for developing an elevated temperature?

Suicidal client who overdosed on a monoamine oxidase (MOA) inhibitor

Which client is most likely to be susceptible to developing a neurogenic fever?

Sustained a head injury in a bicycle crash

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

The nurse learns that different types of headaches respond to different therapies. Which headache is most responsive to nonpharmacologic therapy?

Tension

A client has recently been diagnosed with chronic back pain that requires the daily use of hydromorphone, an opioid analgesic. For the first few weeks, the client achieved relief with 4 mg every 6 hours. However, the client now requires 6 mg doses to achieve the same effect. How should the nurse best interpret this phenomenon?

The client is developing opioid tolerance, which is expected

A client who has been exercising for a few weeks begins to sweat as soon as he exercises. What will the nurse determine from this assessment?

The client is reacting normally.

A student is feeling inside her backpack to find her mobile phone. There are a number of other items in the backpack. Which component of somatosensory conduction is most likely to provide the detailed sensory information that will help her distinguish her phone from other items?

The primary dorsal root ganglion neuron, dorsal column neuron, and the thalamic neuron

Children feel pain just as much as adults do. What is the major principle in pain management in the pediatric population?

Treat on individual basis and match analgesic agent with cause and level of pain.

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

Which characteristic differentiates a migraine with aura from a migraine without aura?

Visual symptoms such as flickering lights precede the headache

Which stimulus would be used to elicit the withdrawal reflex when testing response to nociceptive stimuli?

pressure from a sharp object

While sponging a client who has a high temperature, the nurse observes the client begins to shiver. At this point, the priority nursing intervention would be to:

stop sponging the client and retake a set of vital signs.

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 presents this evidence to the health care provider as supporting which condition?

heatstroke

A nurse's hand-off report states that a client's temperature is 106.6°F (41.4°C). What may have caused the client's temperature to elevate past 105.8°F (41°C)? Select all that apply.

• Convulsions • Hyperthermic state

Which interventions are appropriate for a client with acute pain following abdominal surgery? Select all that apply.

• Hydrocodone • Guided imagery • Cold therapy • Ibuprofen

Clinical manifestations of hypothermia include which signs/symptoms? Select all that apply.

• Impaired coordination • Decreased respirations • Slurred speech

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 possibility of drug interaction • The effects of normal aging on metabolism • The existence of chronic illnesses • The cost of the medication

Which intervention is an appropriate action by a nurse to take in attempting to decrease a client's temperature through conduction?

Apply cooling blanket