Exam 6 Intro

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Chapter 29 Chapter 30 Ms. Rowland

A patient must place his hand on the wall to keep his balance when walking. He leans when sitting and has difficulty knowing when his body is vertical and sensing the position of his body in space. Which type of receptor is probably involved?
1) Photoreceptors
2) Chemoreceptors
3) Proprioceptors
4) Thermoreceptors

3

Which medication might blunt a patient's perception of various kinds of stimuli?
1) Furosemide (Lasix)
2) Metoprolol (Lopressor)
3) Morphine sulfate
4) Metoclopramide (Reglan)

3

A patient complains, "Everything tastes so bland. I add salt, pepper, and sugar to everything just to make it so I can taste it." Which nutrient deficiency might be responsible for his problem? Select all that apply.
1) Vitamin A
2) Vitamin B12
3) Iron
4) Zinc

2, 4

After sustaining an eye injury in a baseball game, a patient complains of blurred and distorted vision. Which visual deficit is this patient most likely experiencing?
1) Macular degeneration
2) Astigmatism
3) Strabismus
4) Glaucoma

2

A patient who has been unable to sleep for several nights has experienced a change in mental status. He does not know what day it is, or where he is. His speech and movements are slowed, and he seems dazed and stupefied. He cannot follow simple directions such as, "Hold out your hand." Which nursing diagnosis is most appropriate for this patient?
1) Chronic Confusion
2) Acute Confusion
3) Impaired Environmental Interpretation Syndrome
4) Impaired Memory

2

A patient in a nursing home is deaf and nearly blind. He is confined to bed most of the time. Which of the following interventions would help to promote optimal sensory function?
1) Keep the television on during waking hours
2) Put colorful artwork on the walls
3) Provide aromatherapy for him
4) Keep the room dark and quiet

3

Ms. Small has sustained a brain attack (stroke/CVA). The nurse notes that the patient is having difficulty placing her affected leg in the correct position when ambulating. This is most likely due to which of the following?
A. Poor directions given to the patient by the physical therapist
B. The patient's lack of proprioception
C. Impaired blood flow to the affected leg
D. The patient's resistance to therapy

B

Mr. Arbor complains to the nurse that he is feeling anxious. He states, "I'm just so tired of all these tests they are doing, and it's so noisy here at night." Mr. Arbor's pulse is 110 bpm, and his blood pressure is 140/70 mm Hg. Nursing actions should include which of the following to address his sensory status?
A. Turn on the television or radio in his room so it will distract him
B. Have the therapist ambulate the patient so he can walk off his anxiety
C. Close the blinds, dim the lights, and ask the patient what other measures would help him rest
D. Call the physician and obtain a prescription for an anti-anxiety medication for PRN use

C

Timothy is hospitalized and in a coma following a traumatic brain injury. Nursing care would include which of the following?
A. Identify yourself when you enter the room and tell him the day and time
B. Tape his eyelids closed securely to prevent the drying of the corneas
C. Limit the families involvement in care so there is more consistency
D. Avoid touching the patient, because this will increase his irritability

A

T or F
Cleaning a patient's hearing aid is a nursing action that will have a positive effect on a sensory deficit.

TRUE

T or F
Xerostomia is the term for loss of smell.

FALSE
Anosmia

T or F
The priority treatment for a patient experiencing acute confusion would be the administration of IV haloperidol (Haldol).

FALSE
Rule out neurological or metabolic cause first

T or F
Loss of hearing can put a patient at risk for social isolation.

TRUE

Anosmia

sense of smell is lost

Xerostomia

excessively dry mouth

RAS

Reticular Activating System
located in brain stem
controls consciousness and alertness

Sensory deprivation

-State of RAS depression caused by a lack of meaningful stimuli
-When environmental stimuli are deficient, minor stimuli (pain, cold, distant noise) can become noticeable or distorted

Sensory overload

-When either evenironment or internal stiuli exceed a higher level that the pt's sensory system can effectively process

Situations that increase the risk for sensory deprivation:

1) impaired sensory reception
2) inability to transmit or process stimuli
3) restricted mobility
4) sensory deficits
5) nonstimulating, monotonous environment
6) being from different culture and unable to interpret received cues

Examples of Sensory deficits:

-impaired hearing
-impaired vision
-impaired taste
-impaired smell
-impaired tactile perception
-impaired kinesthetic sense

Proprioceptors

receptors that detect stretch in muscles to create a mental picture of how the body is positioned

Kinesthesia

muscle sense

Problems of the inner ear commonly impair ?

kinestheia

Activities that enhance proprioception:

1) rhythmic movement
2) aerobic activities
3) strength training
4) flexibility activities
5) balance conditioning with eyes open/closed
6) joints through full range of motion

Glasgow Coma Scale assesses?

eye, motor and verbal responses

Exampes of sensory systems:

1) smell
2) vision
3) hearing
4) touch
5) taste

A 73-year-old patient who sustained a right hip fracture in a fall requests pain medication from the nurse. Based on his injury, which type of pain is this patient most likely experiencing?
1) Phantom
2) Visceral
3) Deep somatic
4) Referred

3

Which pain management task can the nurse safely delegate to nursing assistive personnel?
1) Asking about pain during vital signs
2) Evaluating the effectiveness of pain medication
3) Developing a plan of care involving nonpharmacologic interventions
4) Administering over-the-counter pain medications

1

Which factor in the patient's past medical history dictates that the nurse exercise caution when administering acetaminophen (Tylenol)?
1) Hepatitis B
2) Occasional alcohol use
3) Allergy to aspirin
4) Gastric irritation with bleeding

1

Which action should the nurse take before administering morphine 4.0 mg intravenously to a patient complaining of incisional pain?
1) Assess the patient's incision.
2) Clarify the order with the prescriber.
3) Assess the patient's respiratory status.
4) Monitor the patient's heart rate.

3

Which action should the nurse take when preparing patient-controlled analgesia for a postoperative patient?
1) Caution the patient to limit the number of times he presses the dosing button.
2) Ask another nurse to double-check the setup before patient use.
3) Instruct the patient to administer a dose only when experiencing pain.
4) Provide clear, simple instructions for dosing if the patient is cognitively impaired.

2

The nurse administers codeine sulfate 30 mg orally to a patient who underwent craniotomy 3 days ago for a brain tumor. How soon after administration should the nurse reassess the patient's pain?
1) Immediately
2) In 10 minutes
3) In 15 minutes
4) In 60 minutes

4

Which nonsteroidal anti-inflammatory drug might be administered to inhibit platelet aggregation in a patient at risk for thrombophlebitis?
1) Ibuprofen (Motrin)
2) Celecoxib (Celebrex)
3) Aspirin (Ecotrin)
4) Indomethacin (Indocin)

3

A client who is receiving epidural analgesia complains of nausea and loss of motor function in his legs. The nurse obtains his blood pressure and notes a drop in his blood pressure from the previous reading. Which complication is the patient most likely experiencing?
1) Infection at the catheter insertion site
2) Side effect of the epidural analgesic
3) Epidural catheter migration
4) Spinal cord damage

3

A fentanyl analgesic patch must be changed every ? hrs

72

What pain rating scale would be used to assess pain in a patient with expressive aphasia?

Wong-Baker

The presence of ascites is an example of a type of ? stimuli

mechanical

Mr. Mitchell and Mr. Farrell have both had their gallbladders removed laparoscopically. Mr. Mitchell is rating his pain at a 5 on a 10-point scale and states that he does not require medication. Mr. Farrell is rating his pain at a 5 on a 10-point scale and is demanding something stronger for his pain. This is an example of a difference in which of the following?
A. Surgeons' skill
B. Patients' pain thresholds
C. Patients' personalities
D. Patients' pain tolerances

D

When establishing a plan for pain control, what question would the nurse first ask the patient?
A. "How long have you been having this pain?"
B. "What measures relieve your pain?"
C. "How does the presence of this pain affect your life?"
D. "Aren't you tired of being in pain?"

C

The use of percutaneous electrical stimulation as an effective means to control pain is based on which of the following?
A. Gate-control theory
B. Concept of therapeutic touch
C. Idea of using distraction
D. Theory of using heat application

A

Mr. Zenobia's chronic pain associated with his metastatic prostate cancer has recently increased, and he asks the home health nurse what can be done. In relationship to his long-acting morphine, which of the following is an appropriate response by the nurse?
A. "If you take more morphine, it will not change your pain relief."
B. "I'll call the physician and see if we can get a higher dose."
C. "The amount you are taking now is really all I can give you."
D. "I'm worried if we increase your dose that you will become addicted."

B

T or F
Patients in a coma do not feel pain because they are unconscious.

FALSE

T or F
Experiencing pain is always a negative event for patients.

FALSE

T or F
The liver has more nociceptors than the back of the hand.

FALSE

T or F
A pain-treatment plan should address both the physical and emotional aspects of the client's pain.

TRUE

T or F
A blood pressure of 140/90 mm Hg is obtained during a severe episode of pain; it drops to 120/70 mm Hg. This decrease does not necessarily indicate pain relief.

TRUE

Glasgow Coma Scale

Eyes: 1- Does not open eyes
2- Opens eyes in response to painful stimuli
3- Opens eyes in response to voice
4- Opens eyes spontaneously
Verbal: 1- Makes no sound
2- Incomprehensible sounds
3- Utters inappropriate words
4- Confused, disoriented
5- Oriented, converses normally
Motor: 1- Makes no movement
2- Extension to painful stimuli
3- Abnormal flexion to painful stimuli
4- Withdrawal to painful stimuli
5- Localizes painful stimuli
6- Moves to commands

An apple cart has a Glasgow Coma Scale rating of?

3

What is the range of Glasgow Coma Scale ratings

3-15

What enables people to experience the world around them?

Their senses

Your senses provide informatin about the ? and ?

internal and external environment

Components of Sensory experience:

1) Stimulus
2) Reception
3) Perception

What is a Stimuli/stimulus?

sight
sound
taste
touch
pain
anything that stimulates a nerve receptor

What is Reception?

-process of receiving stimuli from nerve endings in the skin and inside the body
-receptor converts a stimulus to a nerve impulse

What is Perception?

Ability to interpret the impulses transmitted from the receptors and give meaning to the stimuli.

Perception of a stimulus is affected by several factors:

1) location of receptors and pathway activated
2) number of receptors activated
3) frequency of action potentials generated
4) changes in location, # or frequency

Factors affecting Sensory function:

1) Age
2) Culture
3) Illness and medications
4) Stress
5) Personality and lifestyle

Sensory Function in infants:

-track objects and respond to light
-hearing especially acute at low frequency
-discriminate btwn different tastes (pref sweet over sour)
-react to odors
-discriminate btwn mother's breast milk and other woman
-sense of touch keenly present at birth
-require sensory stimulation to grow and develop
-exposure to voices, music, ambient noise develops auditory NS
-light color contrast allow infant to observe work in which they live

Sensory Functions in Older adults:

-experience a generalized decrease in the # of nerve conduction fibers (slower reflexes, delayed response)
-structural changes in eye and ear
-sensory decline may cause withdrawl, depression, social isolation, hallucinations

What causes reversal anosmia?

Zinc deficiency
Heavy smoking
Cocaine use
Rhinitis
Sinusitis

Permanent anosmia may develop after?

Cranial nerve damage
Tumor
Atherosclerosis

Most common reason for impaired taste?

xerostomia (excessively dry mouth)

Medications that affect taste:

antibiotics
anticonvulsants
antihistamines
antihypertensives
chemo agents
lithium carbonate
antipsychotics
antidepressants
statins
muscle relaxants

Response to stimulus is based on following:

1) intensity
2) contast
3) adaptation
4) previous experience

Explain intensity response:

more intense stimulus excites more receptors, leading to greater response

Explain contrast response:

eg. being cold and entering a heated room

Explain adaptation response:

new stimuli, as opposed to stimuli we have become accustomed to

Explain previous experience in sensory response:

prior experience with a stimulus informs our response to same stimulus

What is pain?

unpleasant sonsory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage

Origins of pain:

1) Cutaneous or superficial pain
2) Visceral pain
3) Deep somatic pain
4) Radiating pain
5) Referred pain
6) Phantom pain
7) Psychogenic pain

Pain arising from the mind:

Psychogenic pain

Pain arising form skin or subcutaneous tissue:

Cutaneous pain

Pain perceived originating from an area removed:

Phantom pain

Pain caused by stimulation of deep internal pain receptors. Most often experienced in ab cavity, cranium, thorax

Visceral pain

Pain occuring in an area that is distant from original site.

Referred pain

Pain originates in ligaments, tendons, nerves, blood vessels, and bones

Deep somatic pain

Pain that starts at the origin but extends to other locations

Radiating pain

Pain that is described as achy, crampy

Visceral pain

Types of pain:

1) Nociceptive pain
2) Neuropathic pain

Nociceptive pain

-most common type
-nociceptors respond to stimuli that are potentially damaging
-most commonly described as aching
-visceral pain and somatic pain

Neuropathic pain

-complex and often chronic pain arising from injury to one or more nerves

3 types of Duration of pain:

1) Acute
2) Chronic
3) Intractable

Pain that is both chronic and highly resistant to relief:

Intractable

Pain that last 6+ months and interfers with daily activities

Chronic

Pain that is short in duration and generally has rapid onset

Acute

Factors that influence pain?

1) emotions
2) Developmental stage
3) Sociocultural factors
4) Communication and cognitive impairment

Emotions that influence pain:

Fear
Confusion
Helplessness
Anger
Depression
Previous pain experience

How do sociocultural factors influence pain?

-learn behaviors associated w/ pain throu interaction w/ family and social support groups

Nonverbal cues of pain:

decreased activity
grimacing
frowning
crying
moaning
irritability

Indicators in cognitively impaired pts in pain:

facial expressions
vocalizations
changes in physical activity
changes in routines
mental status change
physiological cues (elevated BP, R, P)

T or F
Absence of cues does not automatically mean that pain is absent.

TRUE

Tolerance

pt needs higher dose to achieve same result

How can you avoid tolerance in pt?

rotate opioids, new opioid compounds
change route of administration
increase dose

Physical dependence

when withdrawl of the drug will cause symptoms

How do you prevent symptoms from drug withdrawl?

slowly withdrawl drug

Psychological dependence AKA

addiction

Examples of adjuvant analgesics:

anticonvulsants
antidepressants
local anesthetics
topical agents
psychostimulants
muscle relaxants
neuroleptics
corticosteroids

What do adjuvant analgesics do?

reduce the amount of opioid the patient requires

Placebo def

any medication or procedure, including surgery, that produces an effect in a pt. because of its implicit or explicit intent, not because of its specific physical or chemical properties

What are chemical pain relief examples?

Nerve blocks
epidural injections
local anesthesia
topical nesthesia

Point at which the brain recognizes and defines a stimulus as pain

Pain threshold

Duration or intensity of pain that a person is willing to endure

Pain tolerance

Types of stimuli that activate nociceptors:

1) mechanical stimuli
2) thermal stimuli
3) chemical stimuli

mechanical stimuli:

external forces that result in pressure or friction against the body

thermal stimuli:

exposure to extreme heat or cold

chemical stimuli:

can be internal or external
-lemon juice (external)
-chemical changes that occur during MI (internal)

Nursing def of pain

Pain is whatever the person says it is and existing whenever the person says it does

Interventions for visual deficits:

-make sure eyeglasses clean, good repair, right rx
-offer magnifying lens, large print books
-provide enough light
-provide sunglasses, hat when pt outdoors

Interventions for hearing deficits:

-encourage pt to wear hearing aid
-make sure aid is functioning
-inspect ear canal for cerumen
-closed captioned tv
-provide written instructions

Interventions for olfactory deficits

-check smoke detectors
-check food expiration date or other signs for food spoilage

Interventions of Gustatory deficits

-check fit of dentures
-offer frequent oral hygiene
-assess for oral sores
-teach pt to eat foods separately or drink water btwn

Interventions for tactile deficits

-foot/lower leg assessment
-stimulate by brushing hair, back rub, touch while giving care
-frequent turning or positioning
-minimize irritating stimuli: keep bed linens loose, bed cradle

Interventions for confused clients

-promote orientation
-simplify your communication
-decrease anxiety
-provide for safety
-provide continuity of care when possible

Interventions for unconscious pt

-unable to interact with you, but needs to be oriented nevertheless
-include pt's support persons in care
-frequent eye care
-bed down, siderails up

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