Chapter 14: Somatosensory Function, Pain, Headache, and Temperature Regulation

Place the four successive stages of fever in correct order. Defervescence Prodromal Flush Chill

Prodromal Chill Flush Defervescence 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.

Which assessment finding correlates to the prodromal stage of a fever? Fatigue Shivering Reddened skin Diaphoresis

Fatigue The reactions that occur during fever consist of four stages: a prodromal period with nonspecific complaints, such as mild headache and fatigue; a chill, during which the temperature rises; a flush, during which the skin becomes warm and flushed; and a defervescence stage, which is marked by the initiation of sweating.

How will the nurse explain to a client the changes in blood flow during exercise? "Heat dilates blood vessels and increases local blood flow to skeletal muscles." "Blood vessels to organs dilate during exercise." "Blood vessels to skeletal muscles constrict during exercise." "Blood vessel size remains constant during exercise."

"Heat dilates blood vessels and increases local blood flow to skeletal muscles." As the client exercises, blood vessels to skeletal muscles dilate to increase blood flow. Blood vessels to the organs constrict.

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." "You just had surgery. Are you sure you are not having any pain?" "I can come back in an hour to see if you are having any pain then." "Are you afraid of becoming addicted if I give you any pain medication?"

"You seem to be uncomfortable. Pain is common with surgery. I can bring you pain medication." Older adults are often reluctant to report pain if it might be a bother to others, or they assume they should experience pain as a result of increased age and health issues. The nurse needs to be specific in asking questions about the pain an older adult is experiencing while using therapeutic communication skills. A closed-ended question will not provide as much data as more open-ended responses will.

Infants are at greater risk of hypothermia than children because of which of the following? A high ratio of surface area to body mass Their inability to remove clothing An increased thickness of subcutaneous fat at birth The inability of infants to state that they are cold

A high ratio of surface area to body mass 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.

A nurse who is testing a client's response to passive movement of the fingers with the client's eyes closed notes that the client cannot accurately identify on which side the movement occurred or in what position the finger was placed. What is an appropriate interpretation of this result? Normal reflex function That the sense of proprioception is intact Abnormal discrimination pathway function Intact thermal sensations

Abnormal discrimination pathway function The discriminative dorsal column-medial lemniscus pathway is able to sense fine touch and discriminate between two points as close as 5 mm. This pathway also mediates sense of position. Loss of this pathway means only that the anterolateral pathway is functioning and is unable to make fine distinctions in touch proprioception and points. The test does not test reflexes or temperature.

For which older adult client would pain assessment likely be most challenging for the nurse? A 90-year-old client who takes multiple medications for cardiac and respiratory conditions A 77-year-old client who has sustained burns on the lower part of the body An 82-year-old client who has been diagnosed with diabetes and an anxiety disorder An 87-year-old client with vascular dementia and numerous other health problems, such as heart failure

An 87-year-old client with vascular dementia and numerous other health problems, such as heart failure Pain in older adults has been associated with impaired appetite, increased sleep disturbances, and in some cases a decrease in cognitive functions. Anxiety, polypharmacy, and the presence of acute pain are factors that may also influence the assessment process, but these are more likely to have a bearing on pain treatment and management than on pain assessment.

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? Temperatures in excess of 99.5°F (37.5°C) can result in seizure activity. Lower temperatures inhibit the protein synthesis of bacteria. Antipyretics protect vulnerable organs, such as the brain, from extreme temperature elevation. Most antipyretics have been shown to have little effect on core temperature but alleviate discomforts.

Antipyretics protect vulnerable organs, such as the brain, from extreme temperature elevation. There is little research to support the belief that fever is harmful unless the temperature rises to extreme levels; it has been shown that small elevations in temperature, such as those that occur with fever, enhance immune function. Antipyretics are effective in lowering core body temperature. They alleviate discomforts of fever and protect vulnerable organs, such as the brain, from extreme elevations in body temperature.

A nurse caring for a client with hypothermia anticipates that the client's temperature will be: Below 100°F (37.7°C) Below 97°F (36.1°C) Below 35°C (95°F) Above 40°C (104°F)

Below 35°C (95°F) Hypothermia occurs when the body's core body temperature drops below 35°C (95°F).

Nonshivering thermogenesis occurs in which of the following to help the newborn infant fight hypothermia? Brown fat Adipose tissue Subcutaneous tissue Epidermis

Brown fat Nonshivering thermogenesis occurs in the liver, brown fat tissue, and the brain and helps the newborn infant fight hypothermia.

A client with a rising temperature is pale and has begun to shiver. The nurse reports that the client is in which phase of fever development? Prodrome Chill Flush Defervescence

Chill During the second phase or chill phase of fever development, the client's skin is pale; there is an onset of shivering, a rising temperature, and the sensation of being chilled. Therefore, the nurse should report that the client is in the second or chill phase of fever development.

The loss of heat from the body through the circulation of air currents is known as: Convection Evaporation Radiation Conduction

Convection Convection refers to heat transfer through the circulation of air currents, while radiation is the transfer of heat through air or a vacuum. Conduction is the direct transfer of heat from one molecule to another, and evaporation involves the use of body heat to convert water on the skin to water vapor.

Which risk factor presents the greatest risk for injury in an older adult who is experiencing a dysfunction in temperature regulator function? Acute renal failure Delayed initiation of appropriate treatment Misdiagnosis of pathology Acute dementia

Delayed initiation of appropriate treatment Older adults often have a lower baseline temperature (36.4°C [97.6°F]) than younger persons, and although their temperature increases during an infection, it may fail to reach a level that is equated with significant fever. The absence of fever may delay diagnosis and initiation of antimicrobial treatment. Absence of fever does not result in misdiagnosis. While the remaining options may occur, they are not the greatest risks for injury.

A hiker presents to the emergency department with reports of flu-like symptoms—thirst, nausea, and inability to urinate. Upon assessment, it is determined that the client has a rectal temperature of 102.2°F (39°C) and is tachycardic. These symptoms support a diagnosis of: Heat exhaustion Heat cramps Heatstroke Malignant hyperthermia

Heat exhaustion Clients with these symptoms could be experiencing heat exhaustion or heatstroke. A diagnosis of heat exhaustion is made based on the temperature range higher than 37.8°C (100°F), but below 40°C (104°F), which indicates heatstroke. Heat cramps are slow, painful, skeletal muscle cramps and spasms, usually occurring in the muscles that are most heavily used and lasting for 1 to 3 minutes. Malignant hyperthermia is an autosomal dominant metabolic disorder in which heat generated by uncontrolled skeletal muscle contraction can produce severe and potentially fatal hyperthermia.

Neurogenic fevers begin in the central nervous system. By what characteristics are neurogenic fevers known? High temperatures that respond quickly to antipyretic therapy Temperatures that go up and down for no apparent reason Variable temperatures that are associated with sweating High temperatures that are not associated with sweating

High temperatures that are not associated with sweating A fever that has its origin in the central nervous system is sometimes referred to as a neurogenic fever. Neurogenic fevers are characterized by a high temperature that is resistant to antipyretic therapy and is not associated with sweating.

A febrile, 3-week-old infant is currently undergoing a diagnostic workup to determine the cause of the fever. Which statement best conveys the rationale for this careful examination? The immature hypothalamus is unable to perform normal thermoregulation. Infants are susceptible to serious infections because of their decreased immune function. Commonly used antipyretics often have no effect on the core temperature of infants. Fever in infants is often evidence of a congenital disorder rather than an infection.

Infants are susceptible to serious infections because of their decreased immune function. Fever in infants and children can be classified as low risk or high risk, depending on the probability of the infection progressing to bacteremia or meningitis and signs of toxicity. Infants between the ages of 1 to 28 days with fever should be considered to have a bacterial infection that can cause bacteremia or meningitis. Younger children have decreased immunologic function and are more commonly infected with virulent organisms. Infants are at particularly high risk for serious bacterial infections that can cause bacteremia or meningitis. Infants are capable of thermoregulation, and fever is not necessarily indicative of a congenital disorder. Antipyretics are effective in the treatment of fever in infants.

Which statement is true of migraine headaches? The majority of clients have a migraine with aura. Surgical treatments for migraines are indicated if pharmacologic treatments are unsuccessful. Migraines may have a hormonal etiology in some clients. Opioid analgesics achieve adequate pain control in most clients.

Migraines may have a hormonal etiology in some clients. Although the pathophysiology of migraines is not well understood, it is thought that hormones may underlie their increased prevalence in women. Surgery is not a standard treatment modality, and although most clients require pharmacologic measures of some type, opioid analgesics are not among the most common drug options. The majority of clients have migraines without auras.

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? Notify the physician. Offer the client a cold drink. Document the temperature. Increase intravenous fluid rate.

Notify the physician. 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 nurse needs to assess a 1-year-old child for fever. Which approach will produce the most accurate reading? Rectal Oral Forehead Axillary

Rectal Measurement of core body temperature is important when evaluating fever. The rectal route is considered the most accurate. In adults and older children, the oral route is lower, but still accurate; however, in young children the oral route may be unreliable. Forehead thermometers can predict trends, but are not as accurate as other routes. The axillary route requires up to 10 minutes for the temperature to register appropriately.

A nurse caring for an older adult who has been diagnosed with a urinary tract infection checks the client's temperature on admission and finds that it is 96.6°F (35.9°C). Which statement describes how the nurse should interpret the finding? The client's temperature is normal so the client does not have an infection. The client is exhibiting a normal febrile response to a urinary tract infection. The client may be exhibiting a blunted or absent febrile response. The client's absent febrile response indicates absence of an infection.

The client may be exhibiting a blunted or absent febrile response. The nurse should interpret the finding as a blunted or absence febrile response to the infection. It has been suggested that as many as 30% of older adults with serious infections present with absent or blunted febrile response, and this may delay diagnosis and initiation of antimicrobial treatment.

The health care provider is assessing the functional integrity of all spinal nerves utilizing a pinpoint pressed against the skin. A normal response would be interpreted as: The withdrawal reflex is activated. No response when the pin is pressed. Saying "Ouch" when the pin is pressed. Verifying the intensity of the pin's force of compression.

The withdrawal reflex is activated. Observation of a normal withdrawal reflex rules out peripheral nerve disease, disorders of the dorsal root and ganglion, disease of the myoneural junction, and severe muscle diseases. Having no response is abnormal and may identify neurologic damage. A verbal response is not a reflex response.

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. Always use nonpharmacologic pain management before using pharmacologic pain management. Base treatment of pain on gender and age group. Treat pediatric pain the way the parents want it treated.

Treat on individual basis and match analgesic agent with cause and level of pain. The overriding principle in all pediatric pain management is to treat each child's pain on an individual basis and to match the analgesic agent with the cause and the level of pain.

A client with trigeminal neuralgia usually complains of excruciating pain. Which activities may trigger an acute pain attack? Select all that may apply. Brushing the teeth with lukewarm water Working in the office that has an air duct located directly overhead Spouse other lightly stroking his or her face Applying lipstick Walking outside on a windy day

Working in the office that has an air duct located directly overhead Spouse other lightly stroking his or her face Walking outside on a windy day Trigeminal neuralgia is manifested by facial tics or spasms and characterized by paroxysmal attacks of stabbing pain that usually are limited to the unilateral sensory distribution of one or more branches of the trigeminal cranial nerve (CN V). Although intermittent, the pain often is excruciating and may be triggered by light touch, movement, drafts (like an air duct overhead), and eating. Brushing ones teeth and applying lipstick should not increase the pain.

A client who is scheduled for orthopedic surgery has expressed concern about the risk of malignant hyperthermia. The nurse should reassure the client that the anesthesiologist will: carefully assess the client's genetic risk of the problem. administer dantrolene 30 to 60 minutes before surgery to prevent the problem. intubate the client in order to prevent malignant hyperthermia. administer antipyretics intravenously at the first sign of the problem.

carefully assess the client's genetic risk of the problem. Family history is a significant factor when appraising a client's risk of malignant hyperthermia. Dantrolene is only administered if active treatment is needed. Antipyretics are ineffective. Intubation is necessary during surgery but does not prevent malignant hyperthermia.

A nurse assess an older adult client for signs and symptoms of infection. In the absence of a fever, for which will the nurse assess? Select all that apply. decreased mental status change in functional capacity fatigue weight gain depression

decreased mental status change in functional capacity fatigue Signs and symptoms of infection in an older adult client in the absence of a fever include decreases in mental status and functional capacity, fatigue, weight loss, and weakness. Depression is a mental health clinical diagnosis not associated with infection.

The nurse is implementing distraction strategies for a client who is experiencing pain. Which distraction strategy(ies) will the nurse to implement? Select all that apply. engaging in conversation about the client's hobbies providing the client with earbuds for listening to music encouraging the client to watch a movie offering a deck of cards to the client and visitor offering acetaminophen to the client providing the client with a quiet environment

engaging in conversation about the client's hobbies providing the client with earbuds for listening to music encouraging the client to watch a movie offering a deck of cards to the client and visitor Distraction helps clients divert their attention away from pain and onto other activities. Distraction may provide sensory shielding whereby attention to other stimuli decreases the perception of pain. Any activity that requires some degree of sensory attention such as listening to music, watching a movie, playing cards, or engaging in conversation can work as distraction. Acetaminophen is an analgesic and not distraction. Although some clients may request quiet when coping with pain, this is not a form of distraction.

A client has sought care because of recent malaise and fever. Upon assessment, the client states that for the past week there has been a cycle of high fever in the evening but normal temperature in the mornings. Which fever pattern will the nurse document? recurrent fever remittent fever sustained fever intermittent fever

intermittent fever An intermittent fever is one in which a fever is experienced for part of a day, but then temperature returns to normal at least once during this 24 hours. Sustained and remittent fevers do not involve a return to normal temperature range. A recurrent or relapsing fever pattern is one in which there is one or more episodes of fever, each lasting as long as several days, with 1 or more days of normal temperature between episodes.

A client is experiencing a cluster headache. The client would most likely manifest: severe pain behind the eye. symptoms aggravated by physical activity. sensitivity to light. nausea with vomiting.

severe pain behind the eye. 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.

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? "Avoid children and people with shingles." "Ask your healthcare provider about a herpes zoster vaccine." "Use antiviral drugs as soon as you are exposed." "Apply a topical anesthetic agent."

"Ask your healthcare provider about a herpes zoster vaccine." 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 the point at which a stimulus is perceived as painful." "Pain tolerance is the minimum intensity of pain a client will endure." "Pain threshold is not varied from person to person." "Pain tolerance is not affected by psychological, familial, cultural, and environmental factors."

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

Which core body temperature does a nurse evaluate as being outside the normal range? Select all that apply. 34°C (93.2°F) 35.4°C (95.7°F) 97.2°F (36.2°C) 99.5°F (37.5°C)

34°C (93.2°F) 35.4°C (95.7°F) The normal range for core body temperature is 36.0°C-37.5°C and/or 97.0°F-99.5°F.

Which client may be experiencing the effects of neuropathic pain? A girl whose playground accident resulted in an arm fracture A man with pain secondary to his poorly controlled diabetes An older adult woman with a stage III pressure injury A man whose pain is caused by gastric cancer

A man with pain secondary to his poorly controlled diabetes Conditions that can lead to pain by causing damage to peripheral nerves in a wide area include diabetes mellitus, alcohol consumption, hypothyroidism, rash, and trauma. Fractures, wounds, and cancer pain do not typically have an etiology that is rooted in the neurologic system.

The pathophysiology of heatstroke is believed to result from the direct effect of heat on body cells and the release of cytokines (e.g., interleukins, tumor necrosis factor, interferon) from heat-stressed endothelial cells, leukocytes, and epithelial cells that protect against tissue injury. Which condition cannot be caused by heatstroke? Disseminated intravascular clotting and acute renal failure Acute respiratory distress and rhabdomyoma Rhabdomyolysis and multiorgan failure Disseminated intravascular clotting and multiorgan failure

Acute respiratory distress and rhabdomyoma Heat stroke is a severe, life-threatening failure of thermoregulatory mechanisms resulting in an excessive rise in body temperature—a core temperature greater than 40°C (104°F). The resulting local and systemic inflammatory responses may result in acute respiratory distress syndrome, acute renal failure, disseminated intravascular clotting, multiorgan dysfunction, and rhabdomyolysis. Hyperthermia is also known to cause edema and microhemorrhages in the brain. Rhabdomyoma is a tumor of striated muscle.

Fever in infants and young children is not an uncommon event. Many trips to the pediatrician's office occur because of fever in children ages 1 day to 3 years. Which sign or symptom does not indicate fever in an infant? Avid feeding Hypoventilation Cyanosis Poor tissue oxygenation

Avid feeding Infants with fever may not necessarily appear ill. In infants younger than 3 months, a mild elevation in temperature (i.e., rectal temperature of 38°C [100.4°F]) can indicate serious infection that requires immediate medical attention. Signs of toxicity include lethargy, poor feeding, hypoventilation, poor tissue oxygenation, and cyanosis.

What can the nurse assume about a child's behavior when faced with the need to repeat a painful procedure? Children act to avoid pain based on their memory of past painful events. A child will resist any intervention that involves contact with his or her body. Pain causes similar responses in people regardless of their age. A child will benefit from a matter-of-fact approach on the part of the nurse.

Children act to avoid pain based on their memory of past painful events. Children do feel pain and have been shown to reliably and accurately report pain. They also remember pain. This is evidenced in studies of children with cancer, whose distress during painful procedures increases over time without intervention, and in neonates in intensive care units, who demonstrate protective withdrawal responses to a heel stick after repeated episodes. The other options may not necessarily be true of most children.

A severe type of headache that occurs more frequently in men than women and is described as having unrelenting, unilateral pain located most frequently in the orbit is called: Migraine headache Tension headache Cluster headache Chronic daily headache

Cluster headache Cluster headache is a type of primary neurovascular headache that typically includes severe, unrelenting, unilateral pain located, in order of decreasing frequency, in the orbital, retro-orbital, temporal, supraorbital, and infraorbital region.

The client asks the health care provider, "What is the purpose of applying cold to a sprained ankle?" Which response by the health care provider is best? Cold provides pain relief and suppresses the release of products from tissue damage. Cold dilates the blood vessels and can be left on for as long as needed. Cold causes extravasation of blood into the damaged area. Cold provides alternating vasoconstriction and dilatation when applied locally.

Cold provides pain relief and suppresses the release of products from tissue damage. Cold prevents the release of products of tissue damage and provides pain relief (produces vasoconstriction at the site). Application of heat would cause blood vessels to dilate and more blood to be drawn to the local area.

What is the most common cause of drug fever? Increased heat production from PTU Hypersensitivity reaction to medication Impaired peripheral heat dissipation by atropine Serotonin syndrome

Hypersensitivity reaction to medication 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.

Which sensations will be impaired in a client who has an injury to the primary somatosensory cortex? Select all that apply. Fine touch in the thumb Pressure sense in lips Firm pressure in knees Sense of hot and cold

Fine touch in the thumb Pressure sense in lips Sense of hot and cold The primary somatosensory cortex receives sensory information direct from the thalamus. It is responsible for fine touch and pressure discrimination in the thumb, forefinger, lips, and tongue. Temperature receptors of the thalamus are intermixed with cortical somatosensory regions.

The nurse knows that chronic pain lacks which of the characteristic pain-related reactions? Increased heart rate Loss of appetite Disturbed sleep patterns Depression

Increased heart rate Characteristics of chronic pain do not include autonomic responses like increased heart and respiratory rate. Loss of appetite, disturbed sleep patterns, and depression are common among people dealing with chronic pain.

A nurse teaching a client about the cervical mucus basal body temperature (CMBBT) method of birth control says that during the postovulation time frame, the core body temperature does which of the following? Increases 0.5°C to 1.0°C Increases 1.0°F-1.5°F Decreases 0.5°C-1.0°C Decreases 1.0°F-1.5°F

Increases 0.5°C to 1.0°C During the postovulatory phase, core body temperature rises approximately 0.5°C-1.0°C.

In describing the ideal analgesic, what factors would be included? Select all that apply. Inexpensive Have minimal adverse effects Effective Addictive Decrease the level of consciousness

Inexpensive Have minimal adverse effects Effective 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.

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? Give emotional reassurance. Inform the anesthesiologist. Document the statement. Request that a chaplain visit.

Inform the anesthesiologist. Malignant hyperthermia is an autosomal dominant metabolic disorder that occurs in response to particular triggers such as general anesthesia (particularly halothane, and the depolarizing muscle relaxant succinylcholine), trauma, exercise, environmental heat, and infection. If the uncle experienced this condition, the client could also carry the RYR1 gene. The anesthesiologist could select a different anesthetic agent. While the other actions are important, it is essential that the nurse take action to prevent harm to the client.

Which intervention is usually the first line of therapy when treating moderate pain in the older adult population? Nonopioids such as acetaminophen Opioids such as codeine Antihistamines like diphenhydramine Muscle relaxants like cyclobenzaprine

Nonopioids such as acetaminophen Nonopioids are generally the first like of therapy for mild to moderate pain in the older adult population. Opioids are used for more severe pain and palliative care. Diphenhydramine is used primarily for allergy symptoms. Muscle relaxants like cyclobenzaprine are helpful for aching muscles.

When a peripheral nerve is irritated enough, it becomes hypersensitive to the noxious stimuli, which results in increased painfulness or hyperalgesia. Health care professionals recognize both primary and secondary forms of hyperalgesia. What is primary hyperalgesia? Pain that occurs in the tissue surrounding an injury Pain sensitivity that lasts longer than 1 week Pain sensitivity that occurs in the viscera Pain sensitivity that occurs directly in damaged tissues

Pain sensitivity that occurs directly in damaged tissues Primary hyperalgesia describes pain sensitivity that occurs directly in damaged tissues.

A client reports feeling a tingling sensation in the last two fingers of one hand after hitting the inner surface of the elbow on a desk. What is the cause of this symptom? Paresthesia from temporary nerve compression Hypersensitivity reaction to nerve injury Hyperpathia from localized ischemia Hypoesthesia from an inherited response

Paresthesia from temporary nerve compression Temporary mild compression of a peripheral nerve can lead to paresthesia. Hypersensitivity is an increased response to mild stimuli. Hyperpathia is a syndrome in which pain is explosive after the raised sensory threshold is reached. Hypoesthesia is reduced or lost sensation of touch or temperature and may be an inherited trait.

A nurse caring for a client with mild hypothermia anticipates which assessment findings? Select all that apply. Shivering Decreased heart rate Elevated blood pressure Diuresis

Shivering Elevated blood pressure Diuresis The nurse should anticipate that the client with mild hypothermia would have the following assessment findings: shivering, accelerated heart rate, increased blood pressure, diuresis, and dehydration.

Full localization, discrimination of intensity, and interpretation of somatosensory stimuli requires processing by which region of the brain? Somatosensory cortex Autonomic nervous system Ruffini end-organ receptors Thalamus

Somatosensory cortex The full localization, discrimination of the intensity, and interpretation of the meaning of the stimuli require processing by the somatosensory cortex. The anterolateral pathway gives off numerous branches that travel to the reticular formation of the brain stem; the branches provide the basis for increased wakefulness or awareness after strong somatosensory stimulation and for the generalized startle reaction that occurs with sudden and intense stimuli. They also stimulate autonomic nervous system. Ruffini end-organs are found in the skin and deeper structures and detect tissue vibration, heavy and continuous touch, and pressure. Stretch-sensitive receptors in the skin (i.e., Ruffini endings, Pacinian corpuscles, and Merkel cells) also signal postural information. In the thalamus, sensory information is roughly localized and perceived in a crude sense.

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

Tension 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.

A 33-year-old client is brought into the emergency room with a core temperature of 39°C (102.2°F). The client is red in the face, chest, and back due to significant cutaneous vasodilation. The client is likely in which stage of fever? First Second Third Fourth

Third The first stage of a fever is marked by headache and body aches, the second stage is marked by the chills, and the third stage is the flush state. The fourth stage is defervescence.

A client reports chronic pain. Assessment indicates it is located at the T6 dermatome. How will this information assist the nurse to develop an effective plan of care? Treatment can be tailored to the specific location. Activities of daily living (ADLs) will be compromised. Management can prevent referred pain. Biologic treatment is more effective than psychosocial.

Treatment can be tailored to the specific location. A dermatome is the region of the body wall that is supplied by a single pair of dorsal root ganglia. Isolating the location of the pain allows for focused treatment. Chronic pain is best handled by a multidisciplinary team that includes specialists in areas such as anesthesiology, nursing, physical therapy, social services, and surgery. Management may reduce referred pain but may not alleviate it because the visceral and somatic neurons share the same dorsal horn projections. Clients with chronic pain benefit most from interventions that include physical, emotional, financial, and spiritual components of care. Using biologic treatments alone is less effective than the combination of all modalities.

Which of the following is an accurate method of assessing pain in children ages 3 to 8 years? Using a numeric 1-10 scale Using a word graphic scale Using a faces scale Using physiologic responses

Using a faces scale Children between ages 3 and 8 years can accurately point to a scale of faces that ranges from very tearful to very happy to indicate their pain level. Children older than 8 are accurately able to report pain on a numeric scale, or using words ranging from "none" to "the most I have ever had." Physiologic responses to pain, such as tachycardia and guarding, are not very accurate because they are nonspecific and may not occur with chronic pain.

A recovery room nurse monitoring a client for adverse effects of cold cardioplegia assesses for: Ventricular dysrhythmia Postoperative anxiety Increased intercranial pressure Postoperative migraine

Ventricular dysrhythmia The nurse should assess for ventricular dysrhythmia, decreased cerebral blood flow, and postoperative myocardial depression.

Which characteristic differentiates a migraine with aura from a migraine without aura? Gastrointestinal involvement in the hours leading up to the headache A decrease in mood and affect prior to the headache Lack of response to nonpharmacologic treatments Visual symptoms such as flickering lights precede the headache

Visual symptoms such as flickering lights precede the headache An aura is visual (flickering lights, spots, or loss of vision), sensory (feeling of pins and needles, or numbness), and/or speech disturbance that precedes a migraine. Nonpharmacologic treatments may be used with varying success in both types of migraine, and nausea and vomiting may precede or accompany each. Changes in mood and affect are not central to an aura.

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: administer an extra dose of aspirin. stop sponging the client and retake a set of vital signs. increase the room temperature by turning off the air conditioner and continue sponging the client with warmer water. place a heated electric blanket on the client's bed.

stop sponging the client and retake a set of vital signs. Modification of the environment ensures that the environmental temperature facilitates heat transfer away from the body. Sponge baths with cool water or an alcohol solution can be used to increase evaporative heat losses. More profound cooling can be accomplished through the use of a cooling blanket or mattress, which facilitates the conduction of heat from the body into the coolant solution that circulates through the mattress. Care must be taken so that cooling methods do not produce vasoconstriction and shivering that decrease heat loss and increase heat production.