RN 1424-02 Cognition
A client with acute psychosis has been taking haloperidol for 3 days. When evaluating the client's response to the medication, which comment reflects the greatest improvement?
"I know these voices are not real, but I am still scared of them." Explanation: Knowing that the voices are not real is a reflection that the haloperidol is effective in decreasing psychosis. Restlessness may be a side effect of haloperidol, not an indication of improvement. Awareness of need for activities of daily living is an indicator of improvement. However, recognizing that the voices are not real demonstrates a greater awareness of the client's disorder than the need for hygiene does. Wanting to prepare for discharge before stabilization reflects denial of illness.
Which statement by a client with a seizure disorder who has been prescribed topiramate indicates the client has understood the nurse's instruction about this drug?
"I will drink six to eight glasses of water a day." Explanation: Toxic effects of topiramate include nephrolithiasis, and clients are encouraged to drink six to eight glasses of water a day to dilute the urine and flush the renal tubules to avoid stone formation. Topiramate is taken in divided doses because it produces drowsiness. Although eating fresh fruits is desirable from a nutritional standpoint, this is not related to the topiramate. The drug does not have to be taken with meals.
The nurse is teaching the parents of a 7-year-old child who has been newly diagnosed with absence seizures. The nurse is discussing behavior that may indicate seizure activity. Which of the following information is most appropriate for the nurse to teach about absence seizure activity?
"Look for brief episodes of twitching accompanied by disorientation." Explanation: Absence seizures are brief episodes of staring where awareness and responsiveness are impaired. People who have them usually don't realize when they've had one. There is no warning before the seizure, and the person is completely alert immediately afterward. The most common movements are eye blinks. Other movements include slight tasting movements of the mouth, hand movements such as rubbing the fingers together, and contraction or relaxation of the muscles.
Which client statement indicates an understanding of the risk of alcohol relapse?
"Stopping Alcoholics Anonymous (AA) and not expressing feelings can lead to relapse." Explanation: The statement, "Stopping AA and not expressing feelings can lead to relapse," indicates the client's understanding of risk of relapse. The client is responsible for sobriety and must understand the risk and signs of relapse. Other antecedents to relapse include severe craving, being around users, and severe emotional crises. The other statements place the responsibility for the client's sobriety on someone else.
The nurse teaches an adolescent about returning to school after a concussion. Which statement by the client reflects the need for more teaching?
"Time is the most important factor in my recovery." Explanation: While recovery from a concussion takes time, adequate rest and limiting exertion facilitate recovery. Both physical and cognitive exertion can cause the reemergence of symptoms and delay recovery. As symptoms resolve, clients may slowly return to previous levels of activity.
Tachycardia can result from:
3. fear, pain, or anger.
When palpating the bladder of an adult client, a nurse should identify which finding as normal?
A nonpalpable bladder Explanation: An adult's bladder may not be palpable. An adult's bladder that is palpable is usually firm, smooth, and located 1″ to 2″ (2.5 to 5 cm) above the symphysis pubis.
A client has delirium following a head injury. The client is disoriented and agitated. In which order from first to last should the nurse initiate care for this client? All options must be used.
Approach the client using short sentences. Assure the client's safety. Maintain a quiet environment. Request a prescription for haloperidol. Explanation: The first step in providing care for a client with delirium is to approach the client calmly, introduce oneself, and use short sentences when explaining the care given. The nurse should also assure the client's safety by protecting the client from injury. Maintaining a quiet and calm environment by removing extraneous noises will prevent overstimulation. Pharmacologic intervention is used only when other plans for care are not effective. When the underlying problems related to the head injury are resolved, the delirium likely will improve.
The nurse is assessing the level of consciousness in a client with a head injury who has been unresponsive for the last 8 hours. Using the Glasgow Coma Scale the nurse notes that the client opens the eyes only as a response to pain, responds with sounds that are not understandable, and has abnormal extension of the extremities. What should the nurse do?
Chart the client's level of consciousness as coma. Explanation: The client has a score of 6 (eye opening to pain = 2; verbal response, incomprehensible sounds = 2; best motor response, abnormal extension = 2); a score less than 7 is indicative of coma. While the nurse should continue to speak to the client, at this time the client will not be able to be aroused. The nurse should continue to provide skin care and appropriate alignment, but the client will continue to have a motor response of limb extension. It is not necessary to notify the HCP as this assessment does not represent a significant change in neurological status.
A nurse is assessing an elderly client with senile dementia. Which neurotransmitter condition is most likely to contribute to this client's cognitive changes?
Decreased acetylcholine level Explanation: A decreased acetylcholine level has been implicated as a cause of cognitive changes in healthy elderly clients and in the severity of dementia. Choline acetyltransferase, an enzyme necessary for acetylcholine synthesis, has been found to be deficient in clients with dementia. Norepinephrine is associated with aggression, sleep-wake patterns, and the regulation of physical responses to emotional stimuli, such as the increased heart and respiratory rates caused by panic
In group therapy, a client who has used I.V. heroin every day for the past 14 years says, "I don't have a drug problem. I can quit whenever I want. I've done it before." Which defense mechanism is the client using?
Denial Explanation: A client who states that he doesn't have a drug problem and can quit using drugs at any time — despite evidence to the contrary — is denying drug addiction. Identification is a defense mechanism in which an individual unconsciously assumes the mannerisms of another person or group. In compensation, the client emphasizes positive attributes to compensate for negative ones. In rationalization, the client uses faulty logic to justify his behaviors.
A nurse is caring for a client taking low doses of central nervous system (CNS) depressants. What should the client be evaluated for?
Depression of inhibitions Explanation: Excitation can occur when inhibitory synapses are depressed. Low doses of central nervous system depressants may cause excitability and a loss of inhibitions. Side effects do not include insomnia, extrapyramidal symptoms or an increase in appetite.
A client experiencing paranoid thought distortions states, "The voices are telling me the others are aliens, trying to steal my brain." How should the nurse therapeutically approach this client?
Express doubt and do not argue. Explanation: Paranoid clients develop a delusional system to defend against anxiety. It is best to insert doubt but not ti argue with the client because refuting and arguing with the delusion would just add to the anxiety of the client. Encouraging venting of frustration would not address the thought distortion, and a logical, persistent approach would not be a match with the distorted thinking. Confronting the client could cause the client to become agitated.
The nurse is caring for a client who is confused about time and place. The client has intravenous fluid infusing. The nurse attempts to reorient the client, but the client remains unable to demonstrate appropriate use of the call light. In order to maintain client safety, what should the nurse do first?
Increase the frequency of client observation. Explanation: The first intervention for a confused client is to increase the frequency of observation, moving the client closer to the nurses' station if possible and/or delegating the unlicensed assistive personnel (UAP) to check on the client more frequently. If the family is able to stay with the client, that is an option, but it is the nurse's responsibility, not the family's, to keep the client safe. Wrist restraints are not used simply because a client is confused; there is no mention of this client pulling at intravenous lines, which is one of the main reasons to use wrist restraints. Administering a sedative simply because a client is confused is not appropriate nursing care and may actually potentiate the problem
Assessment of a client who has just been admitted to the inpatient psychiatric unit reveals an unshaven face, noticeable body odor, visible spots on the shirt and pants, slow movements, gazing at the floor, and a flat affect. Which of the following should the nurse interpret as indicating psychomotor retardation?
Slow movements. Explanation: Psychomotor retardation refers to a general slowdown of motor activity commonly seen in a client with depression. Movements appear lethargic, energy is absent or lacking, and performance of activity is slow and difficult. A flat affect reflects a lack of emotion. An unkempt appearance reflects lack of self-care. Avoiding eye contact reflects low self-esteem or suspiciousness.
The nurse is assessing an adolescent 1 hour after admission for a head injury. The nurse identifies that there have been changes since the baseline assessment, including apnea, bradycardia, and a widening pulse pressure. What is the primary reason for the nurse to notify the physician?
The changes suggest that the adolescent's intracranial pressure is increasing. Explanation: Cushing's triad (apnea, bradycardia, and widening pulse pressure) is a hallmark of increasing intracranial pressure, which indicates that the teen's condition is deteriorating.
topiramate
Topamax® Anticonvulsant May be taken without regards to meals, May cause drowsiness, avoid alcohol, contact physician if blurred vision or preorbital pain occurs, spinkles may be placed on small amount of soft food, keep well hydrated to prevent kidney stones
A nurse is caring for a client diagnosed with herpes zoster. Place in chronological order the pathophysiological changes that the nurse would anticipate in assessing the progression of the disease. All options must be used.
Varicella-zoster virus is reactivated. Residual antibodies from the initial infection mobilize but are ineffective. Fever, malaise, and red nodules appear in a dermatome distribution. The virus multiplies in the ganglia, causing deep pain, itching, and paresthesia or hyperesthesia. Vesicles appear, filled with either clear fluid or pus. Varicella-zoster virus is reactivated. Explanation: Herpes zoster is an acute inflammation caused by the herpesvirus varicella-zoster (chickenpox) virus. It develops when the varicella-zoster virus is reactivated. The virus then multiplies in the ganglia, causing deep pain, itching, and paresthesia or hyperesthesia. Vesicles with clear fluid or pus appear. Vesicles ultimately crust and scab and no longer shed the virus. The post herpetic neuralgia that occurs as the last phase may last up to 30 days and continues after the lesions have healed.
A client tells a nurse that he has a rash on his back and right flank. The nurse observes elevated, round, blisterlike lesions filled with clear fluid. When documenting the findings, what medical term should the nurse use to describe these lesions?
Vesicles Explanation: Vesicles are raised, round, serous-filled lesions that are usually less than 1 cm in diameter. Examples of vesicles include chickenpox (varicella) and shingles (herpes zoster). A pustule is a raised, circumscribed lesion that's usually less than 3/8″ in diameter and contains purulent material that gives it a yellow-white color — for example, acne pustule and impetigo. A plaque is a circumscribed, solid, elevated lesion that's more than 3/8″, in diameter — for example, psoriasis. A papule is a firm, inflammatory, raised lesion that's as long as 1/4″ in diameter and that may be pigmented or the same color as the client's skin — for example, acne papule and lichen planus.
Where is S1 the loudest?
apex of heart (mitral valve)
A client has had hoarseness for more than 2 weeks. The nurse should:
assess the client for dysphagia. Explanation: Hoarseness occurring longer than 2 weeks is a warning sign of laryngeal cancer. The nurse should first assess other signs, such as a lump in the neck or throat, persistent sore throat or cough, earache, pain, and difficulty swallowing (dysphagia). Gargling with salt water may lead to increased irritation. There is no indication of infection warranting an antibiotic. An oral analgesic would provide only temporary relief of discomfort if hoarseness is accompanied by a sore throat.
A child with a nut allergy is admitted with a severe reaction for the third time in 3 months. The parent says, "I am having trouble with the food labels." The nurse should first:
assess the parent's ability to read. Explanation: Three severe reactions in 3 months indicate a serious problem with adhering to the prevention plan. The nurse should first determine if the parent can actually read the label. The underlying problem may be that the parent is visually impaired or unable to read. The parent's reading level determines what additional support is needed. Referrals to social service or dietary may be indicated, but the nurse does not yet have enough information about the problem. The nurse would communicate with the HCP after assessing the situation to recommend referrals.
A client is about to have a tympanoplasty, and asks the nurse what the surgical procedure involves. The nurse begins the conversation by:
assessing the client's understanding of what the health care provider (HCP) has explained. Explanation: The nurse should first assess the client's knowledge base. Working within the framework of the client's knowledge and educational level, the nurse then can describe the procedure and its benefits.
The monopolizer
controls the group by dominating conversations.
An older adult woman who is usually meticulous about her appearance and dress arrives today for her 23rd day of radiation therapy. She appears disheveled and emotionally labile, and her responses to the usual questions are a little inappropriate. Her heart rate is 124 bpm, her respirations are 32 breaths/min, and her skin is cold and clammy. These findings would suggest that the nurse should further assess the client for:
delirium Explanation: Tachycardia, tachypnea, moist or clammy skin, and disorientation are classic symptoms of delirium. Clients with panic disorder do not exhibit disorientation. Clients with depression exhibit a flat affect, apathy, and sleep disturbances. Clients with schizophrenia have thought disorders such as hallucinations or delusions. (
The definition of a nihilistic delusion is:
false belief that one is dead or that a calamity is about to occur. Explanation: Nihilistic delusions are false beliefs that one is dead or that a calamity is about to occur. Somatic delusions involve false beliefs about the functioning of the body. Body dysmorphic disorder is characterized by a belief that the body is deformed or defective in a specific way. Apraxia is the inability to carry out motor activities.
A client with slight memory impairment and poor concentration is diagnosed with primary degenerative dementia of the Alzheimer's type. Early signs of this dementia include subtle personality changes and withdrawal from social interactions. To assess for progression to the middle stage of Alzheimer's disease, the nurse should observe the client for:
impaired communication. Explanation: Signs of advancement to the middle stage of Alzheimer's disease include exacerbated cognitive impairment with obvious personality changes and impaired communication, such as inappropriate conversation, actions, and responses. During the early stage of Alzheimer's, subtle personality changes may be present. However, other than occasional irritable outbursts and lack of spontaneity, the client is usually cooperative and exhibits socially appropriate behavior. During the late stage, the client can't perform self-care and may become mute.
An elderly woman experiences short-term memory problems and occasional disorientation a few weeks after her husband's death. She also is not sleeping, has urinary frequency and burning, and sees rats in the kitchen. The home care nurse calls the woman's health care provider (HCP) to discuss the client's situation and background, assess, and give recommendations. The nurse concludes that the woman:
is experiencing delirium and a urinary tract infection (UTI). Explanation: Delirium is commonly due to a medical condition such as a UTI in the elderly. Delirium often involves memory problems, disorientation, and hallucinations. It develops rather quickly. There is not enough data to suggest Alzheimer's disease especially given the quick onset of symptoms. Delayed grieving and adjusting to being alone are unlikely to cause hallucinations.
The aggressor
is negative and hostile and uses sarcasm to degrade others.
The role of the blocker
is to resist group efforts.
A client with schizophrenia has been experiencing auditory hallucinations for many years. One approach that has proven to be effective is for hallucinating clients to:
practice saying, "Go away" or "Stop" when they hear voices. Explanation: Researchers have found that some clients can learn to control bothersome hallucinations by telling the voices to go away or stop. Taking an as-needed dose of psychotropic medication whenever the voices arise may lead to overmedication and put the client at risk for adverse effects. Because the voices aren't likely to go away permanently, the client must learn to deal with the hallucinations without relying on drugs. Although distraction is helpful, singing loudly may upset other clients and would be socially unacceptable after the client is discharged. Hallucinations are most bothersome in a quiet environment when the client is alone, so sending the client to his room would increase, rather than decrease, the hallucinations.
Alzheimer's disease therapeutic responses
redirection Telling the client that she is wrong and then telling her what is right is argumentative and challenging. Arguing with or challenging distortions is least effective because it increases defensiveness. Telling the client about reality indicates awareness of the issues and is appropriate. Acknowledging that misperceptions are part of the disease indicates an understanding of the disease and an awareness of the issues. Turning off the radio helps to limit environmental stimuli and indicates an awareness of the issues.
The ear canal of an infant or young child:
slants upward. Explanation: The ear canal slants up in a younger child and down in an older child or adult.
When reviewing the plan of care for a client with Alzheimer's disease, which intervention would the nurse question?
stress management Explanation: Stress management is not beneficial to the client with Alzheimer's disease because of cognitive impairment, confusion, and short-term memory loss. Reminiscence group, walking, and pet therapy are beneficial.
tympanoplasty
surgical correction of a damaged middle ear, either to cure chronic inflammation or to restore function reconstruction of the eardrum, commonly due to perforation; also called myringoplasty
After a laminectomy, the client states, "The doctor said that I can do anything I want to." Which activity that the client intends to do indicates the need for further teaching?
sweeping the front porch Explanation: Sweeping causes a twisting motion, which should be avoided because twisting can cause undue stress on the recently ruptured disc site, muscle spasms, and a potential recurrent disc rupture. Although the client should not bend at the waist, such as when washing dishes at the sink, the client can dry dishes because no bending is necessary. The client can sit in a firm chair that keeps the back anatomically aligned. The client should not twist and pull, so when making the bed, the client should pull the covers up on one side and then walk around to the other side before trying to pull the covers up there.
The recognition seeker
talks about accomplishments to gain attention.
Which interventions should the nurse use to assist the client with grandiose delusions? Select all that apply.
• Accept the client while not arguing with the delusion. • Focus on the feelings or meaning of the delusion. • Focus on events and topics based in reality. Explanation: For the client with grandiose delusions, the nurse should accept the client but not argue with the delusion to build trust and the client's self-esteem. Focusing on the underlying feeling or meaning of the delusion helps to meet the client's needs. Focusing on events and topics based in reality distracts the client from the delusional thinking. Confronting the client's delusions or beliefs can lead to agitation in the client and the need to cling to the grandiose delusion to preserve self-esteem. Interacting with the client only when based in reality ignores the client's needs and therapeutic nursing intervention
A client who was involved in a motor vehicle accident is admitted to the intensive care unit. The emergency department admission record indicates that the client was hit in the right temporal lobe. A nurse would expect the client to demonstrate the following abnormalities? Select all that apply.
• Amnesia for recent events • Difficulty comprehending language • Decreased hearing Explanation: The temporal lobe controls hearing, language comprehension, and the storage and recall of memories; therefore, the client would likely have difficulty comprehending language, diminished hearing, and amnesia for recent events. Aphasia and personality changes might be expected from injury to the frontal lobe. An ataxic gait would indicate injury primarily to the cerebellum.
A client with schizophrenia is admitted to a healthcare facility. When collecting data about the client, the nurse should document which symptoms as negative symptoms of schizophrenia? Select all that apply.
• Apathy • Blurred affect • Lack of motivation Explanation: Negative symptoms of schizophrenia reflect the absence of normal characteristics. They include apathy, lack of motivation, blunted affect, poverty of speech, anhedonia (diminished capacity to experience pleasure), and antisocial behavior. Positive symptoms of schizophrenia include delusions and hallucinations.
A client, diagnosed with Alzheimer's disease, is a new resident in a long-term care facility. The client has difficulty finding his/her room and is seen wandering into the room of others. When discussing the situation at a multidisciplinary conference, which client centered actions would the nurse suggest? Select all that apply.
• Ensure that the client has prescribed hearing aids and glasses on throughout the day. • Place a box with familiar personal items outside the client's door for visual recognition. • Assign the client to a room close to the nursing station for closer monitoring. • Provide verbal cueing as to where the client's room is located. Explanation: Alzheimer's disease is a chronic, organic mental disorder that involves a progressive, irreversible loss of memory. Disorientation, especially when brought to an unfamiliar environment, is a common occurrence. Safety of the individual is a priority. Client-centered actions would focus on interventions to promote the identification of the client room and reduce the instances of wandering. Visual recognition via memory boxes, ensuring the client has glasses and hearing aids to facilitate orientation, and verbal cueing are helpful in assisting the client. Placing the client in a location where the nursing staff can interact with the new resident is also helpful. Restricting the client's movement to a small area and medically sedating the client is not a standard of care.
An adolescent typically achieves formal operational thought, Piaget's final stage of cognitive development. Which cognitive abilities are achieved during this stage? Select all that apply.
• Flexibility • Complex deductive reasoning • Abstract thinking Explanation: The formal operational thought stage is characterized by adaptability and flexibility, abstract thinking, inductive reasoning, and complex deductive reasoning. During the pre-operational stage, which begins at age 2 years and ends at approximately age 7 years, the child masters representational language and transductive reasoning.
A client is newly diagnosed with Alzheimer's disease. When planning this client's care, the nurse should include which aspects of care? Select all that apply.
• Help the client organize his room. • Provide a safe environment. • Instruct the family regarding the disease progression. • Assess the client's nutritional status. Explanation: Preventing injury is an important goal of care for a client with Alzheimer's disease and can be achieved by providing a safe, structured environment, helping him organize his surroundings, and assessing nutritional level, given that many Alzheimer clients are malnourished. Other care goals include establishing effective communication to help the client and his family adjust to the client's altered cognitive abilities, offering emotional support, teaching the client and his family about the disease, and encouraging the client to exercise to help maintain mobility. Alzheimer's disease cannot be reversed. Cognitive losses cannot be prevented because Alzheimer's disease is an insidious, degenerative dementia that eventually causes disorientation; severe deterioration of memory, language, and motor ability; emotional lability; and physical and intellectual disability.
A client diagnosed with primary degenerative dementia of the Alzheimer's type may be progressing to the middle stage of the disease. To assess for progression to the middle stage of Alzheimer's disease, the nurse should observe for which behavioral changes? Select all that apply.
• Occasional irritable outbursts • Impaired communication • Refusing to cooperate with the nursing staff Explanation: Signs of advancement to the middle stage of Alzheimer's disease include exacerbated cognitive impairment with obvious personality changes, which include outbursts and impaired communication, such as inappropriate conversation, actions, and responses. The clients may become suspicious of others and refuse to cooperate with care. During the early stage of Alzheimer's, subtle personality changes may be present such as inability to recall health history and lack of spontaneity; however, the client is usually cooperative and exhibits socially appropriate behavior. During the late stage, the client cannot perform self-care and may become mute.
The nurse is caring for an older adult with mild dementia admitted with heart failure. What nursing care will be helpful for this client in reducing potential confusion related to hospitalization and change in routine? Select all that apply.
• Reorient frequently to time, place and situation. • Arrange for familiar pictures or special items at bedside. • Spend time with the client, establishing a trusting relationship. Explanation: It is not unusual for the elderly client to become somewhat confused when "relocated" to the hospital, and this may be more difficult for those with known dementia. Frequent reorientation delivered patiently and calmly along with placing familiar items nearby so the client can see them may help decrease confusion related to hospitalization. Establishing a trusting relationship is important with every client but maybe more so with this client. Putting the client in a room further from the nursing station may decrease extra noise for the client, but will also make it more difficult to observe the client and maintain a safe environment. Procedures should be explained to the client prior to proceeding and should not be rushed. Visits by family and friends may help to keep the client oriented.
The nurse is monitoring a client with schizophrenia who is prescribed clozapine. During a multidisciplinary mental health team meeting, which signs and symptoms would be brought to the psychiatrist's attention? Select all that apply.
• Sore throat • Fever • Orthostatic hypotension Explanation: Sore throat, fever, and the sudden onset of other flu-like symptoms are signs of agranulocytosis, an adverse effect of clozapine that would be brought to the psychiatrists' attention. The condition is caused by a deficiency of granulocytes (a type of white blood cell), which causes the individual to be susceptible to infection. The client's white blood cell count would be monitored at least weekly during clozapine treatment. Orthostatic hypotension may occur with initial use of the drug. Dizziness upon standing with or without fainting can also occur during clozapine treatment. Extrapyramidal effects (such as pill-rolling) either does not occur or occur at a much lesser rate with the atypical antipsychotic medications. Polydipsia (excessive thirst) and polyuria (increased urination) are common adverse effects of lithium.
The nurse is caring for a 5-year-old child who is cognitively challenged. The parents ask the nurse how best to foster independence in the child. Which of the following teaching points should the nurse emphasize? Select all that apply.
• Teach one step at a time to facilitate short-term memory. • Use generous praise as a reward for learning. • Limit principles and abstract concepts in the teaching. • Use repetition to reinforce learning. Explanation: Teaching a cognitively challenged child should incorporate teaching one step at a time, using praise and limiting abstract concepts. These steps help the child learn in an environment that is supportive. Teaching a cognitively challenged child within a group of other children may lead to distraction and unsuccessful learning. Children with cognitive challenges need to be in an environment with little extra stimuli so they can focus on learning.
The nurse is collecting data to determine whether a client is experiencing dementia or depression. Which findings indicate dementia? Select all that apply.
• The progression of symptoms is slow. • The family cannot identify when symptoms first appeared. • The client's basic personality has changed. • The client has great difficulty paying attention to others. Explanation: Common characteristics of dementia include slow onset of symptoms, difficulty identifying when symptoms first occurred, noticeable changes in the client's personality, and impaired ability to pay attention to others. Options 2 and 3 are symptoms of depression, not dementia.
A history of which factors will complicate the recovery from a concussion? Select all that apply.
• attention deficit/hyperactivity disorder (ADHD) • depression • migraines • previous concussion Explanation: Concussion recovery can be complicated by any previous brain injury, such as a previous concussion. Recovery can also be complicated by the presence of other neurologic problem, such as migraines, ADHD, and depression. Asthma and obesity have not been linked to concussion recovery.
The client is experiencing parasympathetic responses to pain. What responses should the nurse assess the client for? Select all that apply.
• bradycardia • weakness Explanation: To assess pain properly, the nurse must consider the client's description and the nurse's observations of the client's physical and behavioral responses. Physiologic responses may be sympathetic or parasympathetic in nature. Sympathetic responses are commonly associated with mild to moderate pain and include pallor, elevated blood pressure, dilated pupils, skeletal muscle tension, dyspnea, tachycardia, and diaphoresis. Parasympathetic responses are commonly associated with severe, deep pain and include pallor, decreased blood pressure, bradycardia, nausea and vomiting, weakness, dizziness, and loss of consciousness.
When caring for a client with myasthenia gravis, the nurse should assess the client for which manifestations of cholinergic crisis? Select all that apply.
• ptosis • fasciculation • respiratory rate of 6 and irregular Explanation: Cholinergic crisis is caused by overstimulation at the neuromuscular junction due to increased acetylcholine. The crisis affects the muscles that control eye and eyelid movement, causing fasciculation, ptosis (drooping eyelids) and difficulty chewing, talking, and swallowing. The muscles that control breathing and neck and limb movements are also affected, and respirations become slowed. Salivation is increased. The crisis is reversed with atropine.
Which symptoms are expected indications that a client has alcohol withdrawal delirium? Select all that apply.
• tachycardia • tachypnea • hypertension Explanation: When a client is developing impending alcohol-withdrawal delirium, the initial symptoms are a fast pulse and respiratory rate, and an elevated blood pressure. Red, flushed, dry skin and complaints of thirst occur with diabetic ketoacidosis. Abdominal cramping and severe diarrhea are symptoms of opiate withdrawal