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

A nurse instructing unlicensed assistive personnel (UAP) on temperature regulation includes as part of her teaching that core body and skin temperatures are sensed by which part of the brain?

Hypothalmus Explanation: Core body and skin temperatures are sensed and integrated by the thermoregulatory regions in the hypothalmus.

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

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 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 Explanation: The client is developing a tolerance to the opioid, which is not unexpected and which is not synonymous with addiction. There may be a need to include

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. Explanation: Exercise training helps the body adapt and the rate of sweat production increases to help regulate temperature. For instance, exercise can increase metabolic head production 10-fold. Thermoregulatory responses such as sweating simultaneously increase heat loss, thus keeping body temperature from rising dangerously high. The trained person begins to sweat sooner, often within 1 to 2 minutes of the start of exercise. The client is reacting normally.

A client is said to be in the chill stage of the fever process when the nurse:

observes piloerection on the skin. Explanation: During the second stage or chill, there is the uncomfortable sensation of being chilled and the onset of generalized shaking (rigors). Vasoconstriction and piloerection usually precede the onset of shivering. At this point, the skin is pale and covered with goose flesh. Sweating is an indication of the third stage or flushing. The other options are not descriptive of stages but rather interventions.

A client is experiencing a cluster headache. The client would most likely manifest:

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.

When lecturing about heart attacks (myocardial infarctions), the instructor will emphasize the client may present with: Select all that apply.

substernal chest pain. neck pain. pain that radiates to the left arm. Explanation: Referred pain is perceived at a site different from the location of its point of origin but innervated by the same spinal segment. The sites of referred pain are determined embryologically with the development of visceral and somatic structures that share the same site for entry of sensory information into the central nervous system (CNS) and then move to more distant locations. Pain that originates in the abdominal or thoracic viscera is diffuse and poorly localized and is often perceived at a site far removed from the affected area. For example, the pain associated with myocardial infarction commonly is referred to the left arm, neck, and chest, which may delay diagnosis and treatment of a potentially life-threatening condition.

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." 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.

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." Explanation: As the client exercises, blood vessels to skeletal muscles dilate to increase blood flow. Blood vessels to the organs constrict.

A health educator is teaching a group of colleagues about the physiology of thermoregulation. Which statement is most accurate?

"Prostaglandin E2 (PGE2) exerts a direct fever-producing effect on the hypothalamus." Explanation: PGE2 is the protein that exerts control on the hypothalamus and induces fever. Exogenous pyrogens induce host cells to produce endogenous pyrogens, and Kuppfer cells produce PGE2. Cytokines do not act directly on the hypothalamus.

A beta-adrenergic blocker has been prescribed for a client diagnosed with migraines. The most important information for the nurse to teach the client would be:

"Take the medication daily as you have been directed." Explanation: Preventive medications such as beta-adrenergic blockers should be taken consistently to prevent vascular changes from occurring. In most cases, preventive treatment must be taken daily for months to years. They should not be stopped abruptly and should be weaned or tapered off.

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." Explanation: 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.

Which temperature readings indicate to the nurse that the clients have fever? Select all that apply.

35-year-old with pulmonary artery reading of 37.9ºC (100.2ºF) 19-year-old with oral reading of 38.4ºC (101.1ºF) 3-day-old with rectal reading of 38ºC (100.4ºF) Explanation: A core body temperature reading can be obtained from the esophagus, pulmonary artery catheter, a urinary catheter probe, or the rectum. For rapidly fluctuating temperatures, the pulmonary artery is most accurate. An oral temperature is generally lower than core by about 0.5ºC (1ºF). Axillary temperatures are approximately 0.5ºC (1ºF) lower than oral. A fever is temperature elevation above the body's normal set point which is usually between 36ºC (97ºF) and 37.5ºC (99.5ºF).

Which clients are showing manifestations of infection? Select all that apply.

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.

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

A chill Explanation: The physiologic behaviors that occur during the development of fever can be divided into four successive stages: prodrome, chill, flush, and defervescence. The stages are successive.

A client fell from a ladder and broke his ankle and is being seen in the emergency department for severe ankle pain with swelling and limited range of motion. What type of pain does the nurse recognize the client is experiencing?

Acute pain Explanation: Acute pain is pain that is elicited by injury to body tissues and activation of nociceptive stimuli at the site of local tissue damage. It is generally of short duration and tends to resolve when the underlying pathologic process has resolved. Acute pain's purpose is to serve as a warning system. It alerts a person to the existence of actual or impending tissue damage and prompts a search for medical help.

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:

Cluster headache Explanation: 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.

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.

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.

A client has an increase in core temperature. What does the nurse expect to assess with this finding? Select all that apply.

Dilation of superficial blood vessels Sweating Explanation: Dilation of superficial blood vessels occurs with increased temperature to dissipate heat. Sweating can also occur. Constriction of superficial blood vessels, cool skin, and hyperactivity does not usually occur.

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 Explanation: The probable mechanisms for the blunted fever response in older adults include a disturbance in sensing of temperature by the thermoregulatory center in the hypothalamus. Heat loss by evaporation tends to decrease with age, and the closure of arteriovenous shunts results in increased core temperature. The presence of comorbidities is not noted to contribute to reduced fever response in older adults.

Which assessment finding correlates to the prodromal stage of a fever?

Fatigue Explanation: 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.

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 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 with schizophrenia develops sudden onset of fever, muscle rigidity, altered level of consciousness, and tachycardia. What is the appropriate response by the nurse? Select all that apply.

Hold the neuroleptic medication Administer bromocriptine Give dantrolene Explanation: Neuroleptic malignant syndrome occurs when there is rapid withdrawal of dopaminergic agents (such as those for Parkinson disease) or rapid increase in dosage of neuroleptic agents such as haloperidol. The manifestations include muscle rigidity, change in level of consciousness, and autonomic lability, including changes in temperature, heart, and respiratory rates. Bromocriptine is a dopamine agonist that may reduce the symptoms. Dantrolene is a muscle relaxant used to reduce the muscle rigidity. Fluid intake should be increased to prevent renal failure from myoglobinuria. It is possible the calcium release contributes to the muscle rigidity. An increase of calcium is not advised.

What is the most common cause of drug fever?

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.

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:

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.

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

Increased heart rate Explanation: 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 notes that a client with a fever has begun to shiver. The nurse should assess for which event?

Increased temperature Explanation: The nurse should assess for increased temperature elevation. This is because although shivering is an attempt by the body to decrease temperature, it actually increases it along with oxygen consumption.

In describing the ideal analgesic, what factors would be included? Select all that apply.

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 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?

Infants are susceptible to serious infections because of their decreased immune function. Explanation: 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 bave 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.

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. Explanation: 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.

In which client with a transecting spinal cord injury should the nurse anticipate an impaired ability for temperature regulation?

Injury at T2 Explanation: Spinal cord injuries that transect the cord at T6 or above can seriously impair temperature regulation because the thermoregulatory centers in the hypothalmus can no longer control skin blood flow and sweating. T9, L4, and L1 injuries are below the level of T6 and do not impair the hypothalmus's ability to control skin blood flow and sweating.

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 Explanation: The nurse's hand-off report should include the presence of intermittent fever—a temperature that returns to normal at least once every 24 hours.

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

Intractable pain Explanation: Subarachnoid hemorrhage causes a severe intractable headache. Headaches that disturb sleep or occur with exercise or sexual activity may be caused by neurologic lesions. Migraine headaches tend to run in families but do not contribute to hemorrhage.

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

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

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.

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?

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.

The route considered the most accurate to measure a core body temperature is:

Rectal Explanation: The rectal temperature is used as a measure of core temperature and is least invasive of all of these options.

A client reports having three episodes of fever that have lasted several days, with periods of normal temperature in between the episodes for 2 or more days. Which type of fever is the client experiencing?

Relapsing fever Explanation: A recurrent or relapsing fever is one in which there is one or more episodes of fever that last several days, with one or more days of normal temperature between episodes. With remittent and continuous fever the client does not experience a return to a normal temperature level. Intermittent fever returns to normal at least once every 24 hours, but this is not consistent with the client's description above.

The nurse is providing nonpharmacologic pain relief for a client who has a pain level of 2 in the leg. What intervention provided by the nurse would be considered distraction?

Sitting with the client and having a conversation Explanation: Distraction does not eliminate pain, but it can make pain more tolerable. It may serve as a type of sensory shielding whereby attention to pain is sacrificed to pay attention to other stimuli that are easily perceived. Examples of distraction include counting, repeating phrases or poems, and engaging in activities that require concentration, such as projects, activities, work, conversation, or describing pictures. Television, adventure movies, music, and humor also can provide distraction.

Full localization, discrimination of intensity, and interpretation of somatosensory stimuli requires processing by which region of the brain?

Somatosensory cortex Explanation: 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.

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 Explanation: Stimulus-induced analgesia is one of the oldest known methods of pain relief. Electrical stimulation methods of pain relief include TENS, electrical acupuncture, and neurostimulation. A physical agent would be the use of heat or cold. Distraction is a nonpharmacologic method of reduction of pain by distracting the client from his pain. Biofeedback is used to provide feedback to a person concerning the current status of some body function, temperature, temporal artery pulsation, blood pressure, or muscle tension.

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 Explanation: Overdoses of serotonin reuptake inhibitors, or use by people taking MOA inhibitors, can cause agitation, hyperactivity, and hyperthermia.

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 Explanation: The discriminative pathway, which is associated with the fine touch of item discrimination, involves just three neurons: the primary dorsal root ganglion neuron, the dorsal column neuron, and the thalamic neuron. Slow-conduction and anterolateral pathways that involve the reticular activating system are associated with pain, thermal sensation, and indiscriminate touch.

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?

Third Explanation: 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 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?

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.

Which pain disorder is a manifestation of a disruption of cranial nerve function?

Trigeminal neuralgia Explanation: 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). Cranial nerve involvement is not implicated in postherpetic neuralgia, phantom limb pain, or TMJ syndrome.

A recovery room nurse monitoring a client for adverse effects of cold cardiplegia assesses for:

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

Which client most likely faces the highest risk of neuroleptic malignant syndrome?

Young adult client who is taking antipsychotic medications for the treatment of schizophrenia Explanation: Antipsychotics are often implicated in cases of neuroleptic malignant syndrome. Surgery, medications for Alzheimer disease, and fever are not risk factors.