Chapter 04 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

Chapter 04 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

Question 1

Type: MCSA

A patient complains of a dull, aching sensation in the lower back after long periods of sitting. The nurse anticipates the administration of medication to suppress pain impulse transmission in which fibers to treat the patient’s complaint?

1. A delta fibers
2. C fibers
3. Myelinated fibers
4. Enkephalins

Correct Answer: 2

Rationale 1: A delta fibers conduct impulses rapidly. Sharp, pinprick-like pain is conducted along these fibers.

Rationale 2: C fibers have a slow conduction rate and transmit aching, throbbing sensations.

Rationale 3: Nerves termed unmyelinated C fibers transmit aching and throbbing sensations to the brain.

Rationale 4: Enkephalins are endogenous opioid peptides that participate in the modulation of pain.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4-1

Question 2

Type: MCSA

A patient has received a pain medication that blocks pain signals from the spinal cord. The nurse anticipates the effects of this medication will result in which level of pain?

1. 0 on a scale from 0–10
2. 8 on a scale from 0–10
3. 5 on a scale from 0–10
4. 2 on a scale from 0–10

Correct Answer: 1

Rationale 1: Pain signals that are blocked at the spinal cord will not be transmitted to the brain so these signals will not cause pain.

Rationale 2: Since the pain signal is being blocked or interrupted at the spinal cord, the pain will not be severe.

Rationale 3: Since the pain signal is being blocked and not transmitted to the brain pain will not be moderate.

Rationale 4: Since the pain signal is blocked at the spinal cord and is not being transmitted to the brain mild pain will not be present.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4-1

Question 3

Type: MCSA

The intensive care nurse plans to test nociception in the patient with a closed-head injury. Which nursing action is indicated?

1. Move an object across the patient’s visual field.
2. Place a container of ground coffee close to the patient’s nostrils.
3. Ask the patient to squeeze and release the nurse’s hand.
4. Press the patient’s nail bed.

Correct Answer: 4

Rationale 1: Testing ocular movement is not associated with nociception.

Rationale 2: Observing the patient’s reaction when a scent is placed close to the nostril is not painful, so it does not test nociception.

Rationale 3: Squeezing and releasing the nurse’s hand on command provides neurological assessment data; however, this action should not be painful to the patient.

Rationale 4: Nociception refers to the activation of pain receptors to the point of pain. Pressing the patient’s nail bed can elicit a motor response to pain that provides evidence of nociception.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4-1