Unit 5 Chapter 14 Path Flashcards
Why does subcutaneous fat affect the body’s ability to insulate itself? Select all that apply.
A) Its poor ability to conduct body heat
B) The tendency of its blood vessels to vasodilate
C) Its ability to produce body heat
D) It adds thickness to the body’s outer shell
E) It decreases the body’s need to shiver to produce heat
A) Its poor ability to conduct body heat
D) It adds thickness to the body’s outer shell
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.
The loss of heat from the body through the circulation of air currents is known as:
A) Radiation
B) Convection
C) Conduction
D) Evaporation
B) 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.
What can the nurse assume about a child’s behavior when faced with the need to repeat a painful procedure?
A) Children act to avoid pain based on their memory of past painful events.
B) Pain causes similar responses in people regardless of their age.
C) A child will benefit from a matter-of-fact approach on the part of the nurse.
D) A child will resist any intervention that involves contact with his or her body.
A) 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.
The nurse learns that different types of headaches respond to different therapies. Which headache is most responsive to nonpharmacologic therapy?
A) Cluster
B) Tension
C) Sinus
D) Migraine
B) 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 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:
A) “Take the medication only when feeling a migraine start.”
B) “Take the medication daily as you have been directed.”
C) “Stop this medication immediately if you have dizziness after taking it.”
D) “This medication will prevent you from having any more migraines.”
B) “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.
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:
A) Visual disturbances
B) Dysphasia
C) Lethargy
D))Dizziness
A) 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.
A surgical client is at greatest risk for hypothermia during a surgical procedure related to:
A) impaired thermoregulatory mechanisms brought on by anesthesia.
B) negligence of the anesthesiologist in regulating the body temperature.
C) the instillation of warmed intravenous fluids that lower the core temperature.
D) the decreased temperature of the surgical suite caused by electrical appliances.
A) 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.
The health care provider will likely prescribe which medication to a client who is experiening severe nausea and vomiting with a migraine?
A) caffeine injection
B) dihydroergotamine, an ergotamine derivative
C) oral ondansetron, an antiemetic
D) sumatriptan intranasal spray
D) 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 knows that chronic pain lacks which of the characteristic pain-related reactions?
A) Depression
B) Increased heart rate
C) Disturbed sleep patterns
D) Loss of appetite
B) 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.
Select the tactile receptors that are sensitive to the movement of very light objects over the surface of the skin.
A) Ruffini end-organs
B) Meissner corpuscles
C) Free nerve endings
D) Merkel disk
B) 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.
Infants are at greater risk of hypothermia than children because of which of the following?
A) The inability of infants to state that they are cold
B) Their inability to remove clothing
C) A high ratio of surface area to body mass
D) An increased thickness of subcutaneous fat at birth
C) 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.
Which type of thermometer is the best to use in determining an accurate temperature during an episode of hypothermia?
A) Oral thermometer
B) Electrical thermistor
C) Rectal thermometer
D) Mercury thermometer
B) Electrical thermistorRationale: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.
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:
A) No response when the pin is pressed.
B) Saying “Ouch” when the pin is pressed.
C) The withdrawal reflex is activated.
D) Verifying the intensity of the pin’s force of compression.
C) 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.
The route considered the most accurate to measure a core body temperature is:
A) Rectal
B) Esophageal
C) Thermosensoral (bladder)
D)Thermodilutional (pulmonary artery
A) Rectal
Rationale:The rectal temperature is used as a measure of core temperature and is least invasive of all of these options.
A client is being taught how to use a TENS unit. The nurse determines that teaching was effective when the client states:
A) “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.”
B) “The TENS unit is the easiest and most cost-effective way to manage my pain at home.”
C) “I should take my medication and apply the TENS unit to the painful area as soon as I feel the pain.”
D) “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.”
C) “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.
