Sole Ch 5 Questions and Answers with complete solutions

Sole Ch 5 Questions and Answers with complete solutions Nociceptors differ from other nerve receptors in the body in that they: a) adapt very little to continual pain response. b) inhibit the infiltration of neutrophils and eosinophils. c) play no role in the inflammatory response. d) transmit only the thermal stimuli. - ANS- A Nociceptors are stimulated by mechanical, chemical, or thermal stimuli. Nociceptors differ from other nerve receptors in the body in that they adapt very little to the pain response. A postsurgical patient is on a ventilator in the critical care unit. The patient has been tolerating the ventilator well and has not required any sedation. On assessment, the nurse notes the patient is tachycardic and hypertensive with an increased respiratory rate of 28 breaths/min. The patient has been suctioned recently via the endotracheal tube, and the airway is clear. The patient responds appropriately to the nurse's commands. The nurse should: a) assess the patient's level of pain. b) decrease the ventilator rate. c) provide sedation as ordered. d) suction the patient again. - ANS- A Pulse, respirations, and blood pressure frequently result from activation of the sympathetic nervous system by the pain stimulus. Because the patient is postoperative, the patient should be assessed for the presence of pain and need for pain medication. The assessment of pain and anxiety is a continuous process. When critically ill patients exhibit signs of anxiety, the nurse's first priority is to a) administer antianxiety medications as ordered. b) administer pain medication as ordered. c) identify and treat the underlying cause. d) reassess the patient's hourly to determine whether symptoms resolve on their own. - ANS- C When patients exhibit signs of anxiety or agitation, the first priority is to identify and treat the underlying cause, which could be hypoxemia, hypoglycemia, hypotension, pain, or withdrawal from alcohol and drugs. Both the electroencephalogram (EEG) monitor and the Bispectral Index Score (BIS) or Patient State Index (PSI) analyzer monitors are used to assess patient sedation levels in critically ill patients. The BIS and PSI monitors are simpler to use because they a) can be used only on heavily sedated patients. b) can be used only on pediatric patients. c) provide raw EEG data and a numeric value. d) require only five leads. - ANS- C The BIS and PSI have very simple steps for application, and results are displayed as raw EEG data and the numeric value. The nurse is caring for a patient who requires administration of a neuromuscular blocking agent to facilitate ventilation with nontraditional modes. The nurse understands that NMBAs provide: a) antianxiety effects b) complete analgesia c) high levels of sedation d) no sedation or analgesia - ANS- D Neuromuscular blocking (NMB) agents do not possess any sedative or analgesic properties. The patient is receiving neuromuscular blockade. Which nursing assessment indicates a target level of paralysis? a) Glasgow Coma Scale score of 3 b) Train-of-four yields two twitches c) Bispectral index of 60 d) CAM-ICU positive - ANS- B A train-of-four response of two twitches (out of four) using a peripheral nerve stimulator indicates adequate paralysis. The nurse is concerned that the patient will pull out the endotracheal tube. As part of the nursing management, the nurse obtains an order for a) arm binders or splints b) a higher dosage of lorazepam c) propofol d) soft wrist restraints - ANS- D The priority in caring for agitated patients is safety. The least restrictive methods of keeping the patient safe are appropriate. The primary mode of action for neuromuscular blocking agents used in the management of some ventilated patients is a) analgesia