Unit 5
A parent of a 14-year-old teen expresses concern over the late hours the teen keeps. Which response by the nurse best explains a possible etiology for the late hours? "Teenagers often rebel against parental rules; his body will assure he gets the sleep he needs." "Your teen needs to be prescribed sleep medications to regulate his sleep patterns." "The onset of puberty often lengthens the circadian rhythm, causing an increase in evening wakefulness." "Your teenager is likely responding to pressure from his peers to stay up late."
"The onset of puberty often lengthens the circadian rhythm, causing an increase in evening wakefulness." Circadian rhythms control the sleep-wake patterns; hormonal changes during puberty affect the length of these rhythms, accounting for the changes in sleep patterns. The need for medication is not supported. While teenagers are susceptible to peer pressure and often engage in rebellious behavior, that is not the etiology for the change in adolescent sleep patterns.
Which disease often results in more frequent periods of nighttime awakening and daytime sleeping? Parkinson disease Huntington disease Alzheimer disease Amyotrophic lateral sclerosis (ALS)
Alzheimer disease Persons with Alzheimer disease often have increased periods of nighttime awakening and daytime napping. The other diseases are not associated with increased periods of nighttime awakening and daytime sleeping.
Which intervention is an appropriate action by a nurse to take in attempting to decrease a client's temperature through conduction? Lower the room temperature Give client a warm bath Apply cooling blanket Remove the client's blankets
Apply cooling blanket Conduction is the transfer of heat from one molecule to another. A nurse attempting to use conduction to lower a client's temperature should apply a cooling blanket, as this would conduct heat from the skin to the cool surface of the blanket. Reference:
Intracranial aneurysms that rupture cause subarachnoid hemorrhage in the client. How is the diagnosis of intracranial aneurysms and subarachnoid hemorrhage made? MRI CT scan Loss of cranial nerve reflexes Venography
CT scan The diagnosis of subarachnoid hemorrhage and intracranial aneurysms is made by clinical presentation, CT scan, and angiography. An MRI is not necessary for the diagnosis of subarachnoid hemorrhage and intracranial aneurysm. Loss of cranial nerve reflexes is not diagnostic of subarachnoid hemorrhage and intracranial aneurysm, and neither is venography.
Peripheral nerve disorders are not uncommon. What is an example of a fairly common mononeuropathy? Phalen maneuver Carpal tunnel syndrome Guillain-Barré syndrome Myasthenia gravis
Carpal tunnel syndrome The most common clinical presentation is slowly progressive weakness and atrophy in distal muscles of one upper extremity.
The nurse is caring for a client who has been diagnosed with narcolepsy. The client reports that his muscles become extremely weak when he becomes excited. The nurse understands that the client is describing which of the following? cataplexy sleep paralysis hypnopompic hallucinations hypnagogic hallucinations
Cataplexy is characterized by brief periods of muscle weakness brought about by emotional reactions such as laughter, anger, or fear. Sleep paralysis is a terrifying experience that occurs on falling asleep or on awakening, during which people find themselves unable to move, speak, or even breathe deeply. Hypnagogic hallucinations are vivid hallucinations that occur at the onset of sleep. Hypnopompic hallucinations are hallucinations that may occur on awakening.
The nurse assessing a client with a traumatic brain injury assesses for changes in which neurologic component? Select all that apply. Level of consciousness Metabolic function Motor function Cognition Sensory function
Cognition Level of consciousness Motor function Sensory function Brain injuries can cause changes in level of consciousness and alterations in cognition, motor, and sensory function; therefore, the nurse assessing a client with a traumatic brain injury should assess for changes in these areas.
The nurse knows that which treatment plan listed below is most likely to be prescribed after a computerized tomography (CT) scan of the head reveals a new-onset aneurysmal subarachnoid hemorrhage? Craniotomy and clipping of the affected vessel Administration of a diuretic such as mannitol to reduce cerebral edema and ICP Monitoring in ICU for signs and symptoms of cerebral insult STAT administration of tissue-type plasminogen activator (tPA)
Craniotomy and clipping of the affected vessel Surgery for treatment of aneurysmal subarachnoid hemorrhage involves craniotomy and inserting a specially designed silver clip that is tightened around the neck of the aneurysm. Administration of tPA would exacerbate bleeding and a diuretic would not address the issue of bleeding. Monitoring alone would be an insufficient response given the severity of the problem.
A nurse is discussing sleep hygiene with a client who reports having chronic insomnia. Which are appropriate recommendations? Select all that apply. Maintain a quiet sleep environment that is neither too cold nor too hot. Avoid caffeinated beverages. Establish a regular wakeup time. Drink a glass of wine before bedtime.
Establish a regular wakeup time. Maintain a quiet sleep environment that is neither too cold nor too hot. Avoid caffeinated beverages. Explanation: Sleep hygiene refers to a set of rules and information about personal and environmental activities that affect sleep. These rules include establishing a regular wakeup time to help set the circadian clock and regularity of sleep onset, maintaining a practice of sleeping only as long as needed to feel refreshed, providing a quiet environment that is neither too hot nor too cold, and avoiding the use of alcohol and caffeine before going to bed.
The spinal cord contains the basic factors necessary to coordinate function when a movement is planned. It is the lowest level of function. What is the highest level of function in planning movement? Frontal cortex Cerebral cortex Pons Cerebellum
Frontal cortex The highest level of function, which occurs at the level of the frontal cortex, is concerned with the purpose and planning of the motor movement.
The nurse measures a blood glucose level of 40 mg/dL (2.22 mmol/L) for a client with type 1 diabetes. Why would it be important for the nurse to institute an intervention to elevate the glucose level in this client? Small amounts of glucose may be stored in the brain for a short period of time but are rapidly metabolized. It is not necessary for glucose to be replaced immediately because the client will have enough stored to function for a while. Glucose is not stored in the brain and is a major fuel source for brain function. The nurse should administer a food source of protein in order to increase the glucose level for improved cardiac function.
Glucose is not stored in the brain and is a major fuel source for brain function. Glucose is the major fuel source for the nervous system but neurons have no provision for storing glucose. Ketones can provide for limited temporary energy requirements. However, these sources are rapidly depleted.
The nurse is discussing a 6-year-old pediatric client's sleep characteristics with the child's mother. The mother states that her child sometimes awakens her with fits of crying and appears to be very frightened. The mother asks the nurse what she should do when this happens. What is the most appropriate direction from the nurse? Instruct the mother to help the child settle without trying to awaken the child. Suggest the mother seek a referral for a child psychologist. Instruct the mother to withhold fluids for 3 hours before bedtime. Instruct the mother to awaken the child and reorient the child.
Instruct the mother to help the child settle without trying to awaken the child. The child is most likely experiencing night terrors, which peak between the ages of 5 and 7. The disorder gradually resolves in children and usually disappears during adolescence. There usually is no memory of the episode. The child should be assisted in settling down without awakening. The child must be protected if he or she gets up and walks about during the episodes.
The nurse is explaining to a client's family how vasogenic brain edema occurs. The most appropriate information for the nurse to provide would be: There is a decrease in the amount of fluid volume in the brain. Normal physiologic circumstances result in decreased adsorption of CSF. There is an increase in the production of cerebrospinal fluid volume. The blood-brain barrier is disrupted, allowing fluid to escape into the extracellular fluid.
The blood-brain barrier is disrupted, allowing fluid to escape into the extracellular fluid. Vasogenic brain edema occurs with conditions that impair the function of the blood-brain barrier and allow the transfer of water and protein from the vascular space into the interstitial space. Increased production of CSF and decreased absorption result in hydrocephalus. It occurs in conditions such as hemorrhage, brain injury, and infectious processes
Which process is most likely to occur as a result of a spinal reflex? Pain sensation from a potentially damaging knee movement Peristalsis of the small and large bowel Withdrawal of a hand from a hot stove element Control of oculomotor function in changing light levels
Withdrawal of a hand from a hot stove element A reflex is a highly predictable relationship between a stimulus and an elicited motor response. The withdrawal reflex is stimulated by a painful (nociceptive) stimulus and quickly moves the body part away from the offending stimulus, usually by flexing a limb part. Peristalsis, oculomotor function, and pain are not mediated by spinal reflexes.
Severe head trauma from a coup-contrecoup injury may result in which type of brain injury? development of ataxia cerebrovascular infarction cerebral hematoma arteriovenous malformation
cerebral hematoma The direct contusion of the brain at the site of external force is referred to as a coup injury; whereas, the opposite side of the brain receives the contrecoup injury from rebound against the inner skull surfaces. As the brain strikes the rough surface of the cranial vault, brain tissue, blood vessels, nerve tracts, and other structures are bruised and torn, resulting in contusions and hematomas. Cerebral vascular infarction (stroke) is often caused by atherosclerotic brain vessel occlusions that cause ischemic injuries. Arteriovenous malformations are an underlying condition not associated with trauma head injury. Ataxia describes the lack of muscle coordination when a voluntary movement is attempted. It may affect any motion that requires muscles to work together to perform a function, from walking to picking up an object to swallowing. Ataxia may be inherited and caused by a genetic defect or it may be acquired due to structural damage to the cerebellum or spinal cord.
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? remittent fever sustained fever recurrent 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 has been brought to the emergency department following an overdose of insulin that resulted in unconsciousness. When explaining the rationale for this to the family, the nurse will emphasize that neurons: require many amino acids in order to produce enough energy to function properly. must rely on glucose from the blood to meet their energy needs. store glycogen within the brain cavity. can cause the liver to convert triglycerides into energy if needed quickly.
must rely on glucose from the blood to meet their energy needs. Nervous tissue has a high rate of metabolism. Glucose is the major fuel source for the nervous system. Unlike muscle cells, neurons have no glycogen stores and must rely on glucose from the blood or the glycogen stores of supporting glial cells to meet their energy needs. Persons receiving insulin for diabetes may experience signs of neural dysfunction and unconsciousness when blood glucose drops because of insulin excess. Neither amino acid production nor liver conversion of triglycerides will produce the quick energy that the brain requires to function properly.
Which individual is likely to have the best prognosis for recovery from his or her insult to the peripheral nervous system? A 57-year-old female who developed rhabdomyolysis and ischemic injury after a tourniquet application A 26-year-old male who suffered a bone-depth laceration to his shoulder during a knife attack A 32-year-old male who had his forearm partially crushed by gears during an industrial accident A 20-year-old female who had nerves transected during surgery to remove a tumor from her mandible.
A 32-year-old male who had his forearm partially crushed by gears during an industrial accident Crushing-type injuries carry a higher possibility of nerve function recovery than do lacerations and insults resulting from ischemia. Nerves that have been surgically cut will never recover.
A nurse is performing an intake assessment for a client admitted to the hospital with hypertension. The client informs the nurse that she drinks alcohol in the evening to help her sleep. What does the nurse know about the induction of sleep through alcohol intake? Alcohol along with the concurrent use of melatonin in moderation will help with acute insomnia. Alcohol induces sleep initially and disrupts and fragments sleep. Alcohol is a stimulant and will cause a delay in the induction of sleep. Alcohol will help induce a deep sleep that the client will awaken from refreshed in the morning.
Alcohol induces sleep initially and disrupts and fragments sleep. Although alcohol initially may induce sleep, it often causes disrupted and fragmented sleep. Sleep also is disrupted in people undergoing alcohol- or sleep-medication withdrawal. Alcohol also can lead to poor quality sleep and is related to insomnia.
A teenager has been in a car accident and experienced an acceleration-deceleration head injury. Initially, the client was stable but then started to develop neurological signs/symptoms. The nurse caring for this client should be assessing for which type of possible complication? Status epilepticus TIAs and cerebrovascular infarction Momentary unconsciousness Brain contusions and hematomas
Brain contusions and hematomas Contusions (focal brain injury) cause permanent damage to brain tissue. The bruised, necrotic tissue is phagocytized by macrophages, and scar tissue formed by astrocyte proliferation persists as a crater. The direct contusion of the brain at the site of external force is referred to as an acceleration injury, whereas the opposite side of the brain receives the deceleration injury from rebound against the inner skull surfaces. As the brain strikes the rough surface of the cranial vault, brain tissue, blood vessels, nerve tracts, and other structures are bruised and torn, resulting in contusions and hematomas. TIAs and cerebral vascular infarction (stroke) are often caused by atherosclerotic brain vessel occlusions that cause ischemic injuries. In mild concussion head injury, there may be momentary loss of consciousness without demonstrable neurologic symptoms or residual damage, except for possible residual amnesia. Status epilepticus is not related to this situation.
Which brain structure makes continuous adjustments that result in smoothness of movement, particularly during delicate maneuvers? Prefrontal lobe Temporal lobe Cerebellum Limbic system
Cerebellum The cerebellum makes continuous adjustments, resulting in smoothness of movement, particularly during delicate maneuvers. The limbic system is involved in emotional experiences and in the control of emotion-related behavior. The prefrontal lobe is thought to be involved in anticipation and prediction of consequences of behavior. The temporal lobe is important in auditory functions and long-term memory recall.
A couple in their 90s is attending a healthy living seminar offered by their nurse practitioner. During the presentation the couple asks if aging causes problems with sleeping. What would be the most accurate response? Aging often causes problems with sleep. As people age they require more sleep. Comorbidities often cause problems with sleep. Most adults over 65 suffer from chronic insomnia.
Comorbidities often cause problems with sleep. Normal aging does not directly cause problems with sleep; however, the medical and psychosocial comorbidities that accompany aging often do contribute to sleep disorders in older adults. As people age they require less sleep. Approximately 30% of older adults suffer from chronic insomnia.
A football player collides violently with the helmet of another player. The helmet protected him from the initial impact, but the movement of the brain in his cranium resulted in bruised and torn tissue with many small hematomas. What term most accurately describes the type of injury this client incurred? Coup Contrecoup Cerebral hemorrhage Coup-contrecoup
Contrecoup The player incurred a contrecoup injury due to the sloshing of his brain against the back of his skull. The direct contusion of the brain at the site of external force is referred to as a coup injury, whereas the rebound injury on the opposite side of the brain is the contrecoup injury. As the brain strikes the rough surface of the cranial vault, brain tissue, blood vessels, nerve tracts, and other structures are bruised and torn, resulting in contusions and hematomas. A CVA is a stroke.
A child is being seen in the emergency department (ED) after ingesting crayons with lead in them. He is disoriented and having seizures. The provider suspects he has which of the following? Viral meningitis Bacterial meningitis Encephalitis Meningioma
Encephalitis Less frequent causes of encephalitis include ingesting toxic substances such as lead. People experience neurologic disturbances such as lethargy, disorientation, seizures, focal paralysis, delirium and coma. Bacterial and viral meningitis are caused by bacterial and viral infections. Meningiomas are a type of brain tumor that are seen in the middle or later years of life.
Which conditions or events commonly trigger neuropathic pain? Select all that apply. Diabetes mellitus Shingles Myocardial infarction Surgery Osteoarthritis
Diabetes mellitus Shingles Neuropathic pain arises from direct injury or dysfunction of the sensory axons of peripheral or central nerves. Nociceptive pain is the result of free nerve ending activation from a source outside of the nervous system that signals actual or impending tissue injury. Diabetes mellitus and various neuralgias, (e.g., postherpetic lesions such as the herpes zoster virus that causes shingles), both impair the nerves.
A nurse is caring for a client diagnosed with Alzheimer disease who sleeps at irregular intervals, having no consistent sleep-wake cycle. The nurse suspects that the client is experiencing: Irregular sleep-wake rhythm Delayed sleep phase syndrome Free-running sleep disorder Advanced sleep phase syndrome
Irregular sleep-wake syndrome is characterized by a lack of consistent pattern to the sleep-wake cycle. It is most common in older adults with neurological disorders, particularly Alzheimer disease.
The emergency room doctor suspects a client may have bacterial meningitis. The most important diagnostic test to perform would be: Blood cultures Sputum culture CT of the head Lumbar puncture
Lumbar puncture The diagnosis of bacterial meningitis is confirmed with abnormal CSF findings. Lumbar puncture findings, which are necessary for accurate diagnosis, include a cloudy and purulent CSF under increased pressure. The other options do not confirm the diagnosis.
The client states having periods of being "unaware of surroundings" and "falling asleep during the day." The client is scheduled for an electroencephalogram (EEG) to determine if there is seizure activity or a sleep disturbance. What will the nurse teach the client about the purpose of the EEG? Measuring the activity of a single neuron Measuring the combined activity among neurons to a given stimulus Using low voltage to stimulate the brain into activity to simulate a seizure Measuring periods of apnea and hypopnea
Measuring the combined activity among neurons to a given stimulus Explanation: During the recording of an EEG, the postsynaptic potentials are averaged and filtered to improve the quality of the signal. As such, the EEG does not measure the activity of a single neuron, but instead the combined activity and cross talk among many hundreds of neurons responding to a given stimulus.
In which stage of sleep does dreaming occur most frequently? Rapid eye movement sleep Stage I Stages 3 and 4 Non-rapid eye movement sleep
Most dreaming occurs in rapid eye movement (REM sleep). Stages 1, 3, and 4 are parts of non-REM sleep, and dreaming does occur in most stages of sleep.
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? The client is experiencing neuropathic pain. 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. Nociceptive afferents are conducting along the cranial and spinal nerve pathways of the ANS.
Nociceptive afferents are conducting along the cranial and spinal nerve pathways of the ANS. 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 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. Increase intravenous fluid rate. Offer the client a cold drink. Notify the physician.
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.
Which chemical does blood-brain and CSF-brain barrier control with easy entrance? Potassium Oxygen Glutamate Protein
Oxygen Two barriers, the blood-brain barrier and the cerebrospinal fluid (CSF)-brain barrier, provide the means for maintaining the stable chemical environment of the brain. Only water, carbon dioxide, and oxygen enter the brain with relative ease. Large molecules such as proteins are largely excluded from crossing the blood-brain barrier. In the brain, ammonia is converted to glutamine by astrocytes. Potassium has controlled entrance into the brain; the result of slight fluctuations of potassium concentration in the brain would be uncontrolled neural activity because ions such as potassium influence the threshold for neural firing.
What disease results from the degeneration of the dopamine nigrostriatal system of the basal ganglia?
Parkinson disease is a neurodegenerative disorder originating from the basal ganglia. It presents with tremor, rigidity, and difficulty initiating voluntary movements due to progressive destruction of the nigrostriatal pathway, and decreased dopamine levels. Huntington disease is an inherited disorder primarily affecting neurons of the caudate nucleus and putamen of the basal ganglia. Myasthenia gravis is a disorder caused my autoimmune destruction of acetylcholine receptors of muscles. Guillain-Barré syndrome is an acute immune-mediated polyneuropathy leading to rapidly progressive ascending symmetrical limb weakness and loss of tendon reflexes
The basis for assessing the function of any peripheral nerve lies in which principle? Peripheral nerves contain processes of more than one of the four afferent and three efferent cell columns. Peripheral nerves contain only efferent processes from the cell columns. Peripheral nerves contain only afferent processes from the cell columns. Peripheral nerves contain no processes from the seven cell columns.
Peripheral nerves contain processes of more than one of the four afferent and three efferent cell columns. With rare exceptions, peripheral nerves (including the cranial nerves) contain afferent and efferent processes of more than one of the four afferent and three efferent cell columns. This provides the basis for assessing the function of the any peripheral nerve.
The parent of a toddler with Duchenne muscular dystrophy reports that the child has an increase in muscle size but a decrease in strength. The nurse documents this using which medical term? Fasciculations Pseudohypertrophy Dysdiadochokinesia Chorea
Pseudohypertrophy, as occurs with Duchenne muscular dystrophy (DMD), refers to an increase in bulk without an accompanying increase in strength.
A client with a diagnosis of myasthenia gravis underwent a mastectomy. The surgery was a success, but the client has gone into a myasthenic crisis on postoperative day 1. Which priority measure should the care team initiate immediately? Respiratory support and protection of the client's airway Monitoring the client for painful dyskinesias Seizure precautions with padded side rails and bed at lowest height Positioning the client to minimize hypertonia and muscle rigidity
Respiratory support and protection of the client's airway Myasthenic crisis occurs when muscle weakness becomes severe enough to compromise ventilation to the extent that ventilatory support and airway protection are needed. Seizures, dyskinesias, hypertonia, and muscle rigidity are not associated with myasthenia gravis in general or myasthenic crisis in particular.
A client is devastated to receive a diagnosis of amyotrophic lateral sclerosis (ALS). The symptomatology of this disease is a result of its effects on upper and lower motor neurons. The health care provider caring for this client will focus on which priority intervention for this client? Assessment of lower extremities to prevent deep vein thrombosis Ability to turn from side to side, thereby preventing skin breakdown Ability to empty bladder completely, thereby preventing autonomic dysreflexia Respiratory ventilation assessment and prevention of aspiration pneumonia
Respiratory ventilation assessment and prevention of aspiration pneumonia Amyotrophic lateral sclerosis is a mixed upper motor neuron (UMN) and lower motor neuron (LMN) disorder. In the more advanced stages of ALS, muscles of the palate, pharynx, tongue, neck, and shoulders become involved, causing impairment of chewing, swallowing (dysphagia), and speech. Dysphagia with recurrent aspiration and weakness of the respiratory muscles produces the most significant acute complications of the disease. Airway/breathing is always the priority over bladder emptying, skin breakdown, and assessing for DVT.
Which tactile receptors will signal when an athlete experiences a joint injury? Meissner corpuscles Merkel discs Ruffini end-organs Hair follicle receptors
Ruffini end organs are found in skin and deeper structures like joint capsules. Hair follicle receptors are near the skin surface and respond to light touch. Merkel discs transmit an initial strong signal, but decrease in strength— indicating continuous pressure on the skin. Meissner corpuscles respond to light touch and low-frequency vibration.
A family brings their father to his primary care physician for a checkup. Since their last visit, they note their dad has developed a tremor in his hands and feet. He also rolls his fingers like he has a marble in his hand. The primary physician suspects the onset of Parkinson disease when he notes which abnormality in the client's gait? Slow to start walking and has difficulty when asked to "stop" suddenly Takes large, exaggerated strides and swings arms/hands wildly Hyperactive leg motions like he just can't stand still Difficulty putting weight on soles of feet and tends to walk on tiptoes
Slow to start walking and has difficulty when asked to "stop" suddenly The cardinal symptoms of Parkinson disease (PD) are tremor, rigidity (hypertonicity), and bradykinesia or slowness of movement. Bradykinesia is characterized by slowness in initiating and performing movements and difficulty in sudden, unexpected stopping of voluntary movements. Persons with the disease have difficulty initiating walking and difficulty turning. While walking, they may freeze in place and feel as if their feet are glued to the floor, especially when moving through a doorway or preparing to turn. When they walk, they lean forward to maintain their center of gravity and take small, shuffling steps without swinging their arms.
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? A physical agent Stimulus-induced analgesia Biofeedback Distraction
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.
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 The client's medication should be replaced with nonpharmacologic interventions The opioid should likely be replaced with a nonsteroidal anti-inflammatory drug (NSAID) The client is exhibiting the early signs of opioid addiction
The client is developing opioid tolerance, which is expected 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 nonpharmacologic interventions or NSAIDs, but these do not need to replace the opioid.
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 may be exhibiting a blunted or absent febrile response. The client's absent febrile response indicates absence of an infection. The client is exhibiting a normal febrile response to a urinary tract infection. The client's temperature is normal so the client does not have 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.
A nurse is providing education to a client newly diagnosed with Guillain-Barré syndrome. Which statement reflects accurate information about the course of the disease? Most clients do not sustain residual dysfunction from the disorder. The client can expect prolonged isolation due to contagious viral nature of disorder. The disorder may present with rapid life-threatening symptoms or may present as a slow insidious process. It is an acute disorder that usually resolves after treatment with antibiotics.
The disorder may present with rapid life-threatening symptoms or may present as a slow insidious process. It is a chronic disorder that is often progressive, but may present with life-threatening cardiopulmonary symptoms. Clients need considerable, supportive nursing and medical care. It is not contagious, but a viral connection is suspected as many report a flu-like illness preceding onset of symptoms.
Which message is most likely to be carried by general somatic afferent (GSA) neurons? The sensation of cold when touching ice The message to move the larynx during speech The message to move a finger and thumb Information about the position of a joint
The sensation of cold when touching ice General somatic afferent (GSA) neurons innervate the skin and other somatic structures, responding to stimuli such as those that produce pressure or pain. Initiation of motion is the control of efferent neurons, whereas information about the position of a joint is undercarried by the special somatic afferent (SSA) fibers.
Which type of reflex is stimulated by a nociceptive stimulus? Myotatic reflex Stretch reflex Withdrawal reflex Carotid sinus baroreflex
The withdrawal reflex is stimulated by a damaging (nociceptive) stimulus. The myotatic, or stretch reflex, controls muscle tone and helps maintain posture. The carotid sinus baroreflex assists adjustment of the cardiovascular system at the level of the brain stem.
Which process may increase(s) the permeability of the blood-brain barrier? Select all that apply. Hypovolemia Infection Severely jaundiced infants Hypertension Trauma
Trauma Infection Severely jaundiced infants Acute cerebral lesions, such as trauma and infection, increase the permeability of the blood-brain barrier and alter brain concentrations of proteins, water, and electrolytes. The cerebral capillaries are much more permeable at birth than in adulthood, and the blood-brain barrier develops during the early years of life. In severely jaundiced infants, bilirubin can cross the immature blood-brain barrier, producing kernicterus and brain damage. Hypovolemia and hypertension do not effect the blood-brain barrier.
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 Migraine headache Complex regional pain syndrome Trigeminal neuralgia
Trigeminal neuralgia 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 nurse is treating a client who has been diagnosed with mild obstructive sleep apnea. Which of these are behavioral treatment measures for this disorder? Select all that apply. Proper bed position Use of sedatives Weight loss Avoidance of alcohol
Weight loss Avoidance of alcohol Proper bed position Behavioral measures may be the only treatment needed for people with mild obstructive sleep apnea, including weight loss, eliminating evening alcohol and sedatives, and proper bed positioning.
The spouse of a client admitted to the hospital after a motor vehicle accident reports to the nurse that the client has become very drowsy. The nurse should: prepare the client for EEG testing. contact the physician. assess the client for additional signs/symptoms of increased intracranial pressure. instruct the spouse not to let the client fall asleep until the physician has assessed the client.
assess the client for additional signs/symptoms of increased intracranial pressure. Since decreased alertness and/or drowsiness can be an early sign of increased intracranial pressure, the nurse should assess for additional signs/symptoms of increased intracranial pressure. Then, once the assessment is complete, the nurse should contact the physician as needed. There is no indication that the client will undergo EEG testing at this time and the spouse should not be instructed to keep the client awake.
Which stimulus would be used to elicit the withdrawal reflex when testing response to nociceptive stimuli? weak electrical current damp cotton ball at skin temperature water heated to 9°F (5°C) above skin temperature pressure from a sharp object
pressure from a sharp object Of the stimuli listed, only pressure from a sharp object is sufficient to predictably produce a withdrawal reflex. The stimulus must be sufficient to produce a signal via the pain pathway and elicit a predictable response in the subject. Mild stimuli such as a weak electrical current or contact with objects close to body temperature will not be sufficient.
