Porth (2020) 5th nur 317 Flashcards
Chapter 14
A client is experiencing chest pain that radiates to the left arm and neck. The nurse would interpret this pain as:
Cutaneous
Somatic
Visceral
Referred
Referred
Rationale:Referred pain is pain that is perceived at a site different from its point of origin but innervated by the same spinal segment. Visceral pain originates in the visceral organs and is one of the most common pains produced by disease. Cutaneous pain arises from superficial structures. Somatic pain originates in deep body structures.
A client is said to be in the chill stage of the fever process when the nurse:
determines the client will benefit from a cool sponge bath.
observes piloerection on the skin.
administers an antipyretic medication.
observes the client is sweating.
observes piloerection on the skin.
Rationale: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.
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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:
“Stop this medication immediately if you have dizziness after taking it.”
“Take the medication only when feeling a migraine start.”
“This medication will prevent you from having any more migraines.”
“Take the medication daily as you have been directed.”
Take the medication daily as you have been directed.”
Rationale: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.
Question4 of 20
Which type of thermometer is the best to use in determining an accurate temperature during an episode of hypothermia?
Electrical thermistor
Rectal thermometer
Oral thermometer
Mercury thermometer
Electrical thermistor
Rationale:An electrical thermistor probe is used to monitor temperatures as low as 25°C (77°F). Clinical thermometers, such as oral or rectal thermometers, are not able to register at lower levels that are associated with hypothermia. The use of a mercury thermometer is not recommended because of the hazards associated with mercury.
A client is experiencing a cluster headache. The client would most likely manifest:
severe pain behind the eye.
nausea with vomiting.
sensitivity to light.
symptoms aggravated by physical activity.
severe pain behind the eye.
Rationale: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.
A surgical client is at greatest risk for hypothermia during a surgical procedure related to:
the decreased temperature of the surgical suite caused by electrical appliances.
impaired thermoregulatory mechanisms brought on by anesthesia.
negligence of the anesthesiologist in regulating the body temperature.
the instillation of warmed intravenous fluids that lower the core temperature.
impaired thermoregulatory mechanisms brought on by anesthesia.
Rationale:A surgical client has a higher risk of hypothermia related to impaired thermoregulatory mechanisms brought on by anesthesia and other drugs. The instillation of warmed intravenous fluids is used to increase the core temperature, not lower it. The remaining options related to room temperature and the regulation of body temperature are not relevant.
Clinical manifestations of hypothermia include which signs/symptoms? Select all that apply.
Constricted pupils
Impaired coordination
Decreased respirations
Strong bounding pulse
Slurred speech
Impaired coordination, Decreased respirations, Slurred speech
Rationale:Clinical manifestations of hypothermia include poor coordination, stumbling, slurred speech, irrationality, poor judgment, amnesia, hallucinations, blueness and puffiness of the skin, dilation of the pupils, decreased respiratory rate, weak and irregular pulse, stupor, and coma.
Select the tactile receptors that are sensitive to the movement of very light objects over the surface of the skin.
Meissner corpuscles
Free nerve endings
Ruffini end-organs
Merkel disks
Meissner corpuscles
Rationale:Meissner corpuscles are particularly sensitive to the movement of very light objects over the surface of the skin and low-frequency vibration. Free nerve endings detect touch and pressure. Merkel disks allow for continuous determination of touch against the skin. Ruffini end-organs are involved in heavy and continuous touch and pressure.
The loss of heat from the body through the circulation of air currents is known as:
Convection
Conduction
Radiation
Evaporation
Convection
Rationale:Convection refers to heat transfer through the circulation of air currents, while radiation is the transfer of heat through air or a vacuum. Conduction is the direct transfer of heat from one molecule to another, and evaporation involves the use of body heat to convert water on the skin to water vapor.
A client with a history of migraine headaches tells the physician that he or she usually experiences an aura before the onset of the headache. The client is most likely experiencing:
Dysphasia
Visual disturbances
Dizziness
Lethargy
Visual disturbances
Rationale:Migraine aura is associated with visual symptoms, including flickering lights, spots, or loss of vision; sensory symptoms, including feeling of pins or needles, or numbness; and speech disturbances or other neurologic symptoms.
The route considered the most accurate to measure a core body temperature is:
Thermodilutional (pulmonary artery)
Thermosensoral (bladder)
Rectal
Esophageal
Rectal
Rationale:The rectal temperature is used as a measure of core temperature and is least invasive of all of these options.
Infants are at greater risk of hypothermia than children because of which of the following?
The inability of infants to state that they are cold
A high ratio of surface area to body mass
An increased thickness of subcutaneous fat at birth
Their inability to remove clothing
A high ratio of surface area to body mass
Rationale:Relative to body weight, the body surface of an infant is three times that of an adult and in low-birth-weight infants, the insulating layer of subcutaneous fat is thinner. The inability to communicate their needs or remove clothing is not a primary risk for hypothermia.
The health care provider is assessing the functional integrity of all spinal nerves utilizing a pinpoint pressed against the skin. A normal response would be interpreted as:
The withdrawal reflex is activated.
Saying “Ouch” when the pin is pressed.
No response when the pin is pressed.
Verifying the intensity of the pin’s force of compression.
The withdrawal reflex is activated.
Rationale:Observation of a normal withdrawal reflex rules out peripheral nerve disease, disorders of the dorsal root and ganglion, disease of the myoneural junction, and severe muscle diseases. Having no response is abnormal and may identify neurologic damage. A verbal response is not a reflex response.
Why does subcutaneous fat affect the body’s ability to insulate itself? Select all that apply.
It adds thickness to the body’s outer shell
It decreases the body’s need to shiver to produce heat.
Its poor ability to conduct body heat
Its ability to produce body heat
The tendency of its blood vessels to vasodilate
It adds thickness to the body’s outer shell,
Its poor ability to conduct body heat
Rationale:The subcutaneous fat layer contributes to the insulation value of the outer body shell because of its thickness and because it conducts heat only about one-third as effectively as other tissues. Heat is produced by deeper core tissues such as muscles and viscera. Heat is conserved by vasoconstriction. Subcutaneous fat has no relevance to shivering as a form of heat production.
What can the nurse assume about a child’s behavior when faced with the need to repeat a painful procedure?
Children act to avoid pain based on their memory of past painful events.
A child will resist any intervention that involves contact with his or her body.
A child will benefit from a matter-of-fact approach on the part of the nurse.
Pain causes similar responses in people regardless of their age.
Children act to avoid pain based on their memory of past painful events.
Rationale:Children do feel pain and have been shown to reliably and accurately report pain. They also remember pain. This is evidenced in studies of children with cancer, whose distress during painful procedures increases over time without intervention, and in neonates in intensive care units, who demonstrate protective withdrawal responses to a heel stick after repeated episodes. The other options may not necessarily be true of most children.
A client is being taught how to use a TENS unit. The nurse determines that teaching was effective when the client states:
“Anytime that the setting on my TENS unit needs to be changed I will have to return it to the company and wait for them to deliver a new one.”
“I will need to return to the doctor’s office to have this TENS unit surgically implanted under my skin for the best pain relief.”
“I should take my medication and apply the TENS unit to the painful area as soon as I feel the pain.”
“The TENS unit is the easiest and most cost-effective way to manage my pain at home.”
“I should take my medication and apply the TENS unit to the painful area as soon as I feel the pain.”
Rationale:Early intervention for pain relief is the best practice. The client should understand that he or she should take his or her pain medication and apply the TENS unit. TENS units are noninvasive and should be applied as soon as the client starts to perceive pain. It is often used in conjunction with pain-relieving medication
The health care provider will likely prescribe which medication to a client who is experiening severe nausea and vomiting with a migraine?
sumatriptan intranasal spray
dihydroergotamine, an ergotamine derivative
oral ondansetron, an antiemetic
caffeine injection
sumatriptan intranasal spray
Rationale:First-line agents to treat migraine attacks include acetylsalicylic acid, nonsteroidal anit-inflammatory drugs, ergotamine derivatives, and antiemetics. Nonoral routes of administration may be preferred in people who develop severe pain rapidly or on awakening, or in those with severe nausea and vomiting. Sumatriptan has been approved for intranasal administration. The other medications may be prescribed but, if a client is vomiting, the best alternative is the intranasal sumatriptan.
The nurse learns that different types of headaches respond to different therapies. Which headache is most responsive to nonpharmacologic therapy?
Incorrect optionSinus
Correct optionTension
Unanswered optionCluster
Unanswered optionMigraine
Tension
Rationale:Tension-type headaches often are more responsive to nonpharmacologic techniques, such as biofeedback, massage, acupuncture, relaxation, imagery, and physical therapy, than other types of headache. For people with poor posture, a combination of range-of-motion exercises, relaxation, and posture improvement may be helpful. The other options are usually best treated with medications that focus on the cause of the pain.
A hiker presents to the emergency department with reports of flu-like symptoms—thirst, nausea, and inability to urinate. Upon assessment, it is determined that the client has a rectal temperature of 102.2°F (39°C) and is tachycardic. These symptoms support a diagnosis of:
Heat cramps
Malignant hyperthermia
Heatstroke
Heat exhaustion
Heat exhaustion
Rationale:Clients with these symptoms could be experiencing heat exhaustion or heatstroke. A diagnosis of heat exhaustion is made based on the temperature range higher than 37.8°C (100°F), but below 40°C (104°F), which indicates heatstroke. Heat cramps are slow, painful, skeletal muscle cramps and spasms, usually occurring in the muscles that are most heavily used and lasting for 1 to 3 minutes. Malignant hyperthermia is an autosomal dominant metabolic disorder in which heat generated by uncontrolled skeletal muscle contraction can produce severe and potentially fatal hyperthermia.
The nurse knows that chronic pain lacks which of the characteristic pain-related reactions?
Depression
Disturbed sleep patterns
Increased heart rate
Loss of appetite
Increased heart rate
Rationale: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.
