Nokea
A client is waiting in a triage area to learn the medical status of family members following a motor vehicle accident. The client is pacing, taking deep breaths, and handwringing. Considering the effects in the body systems, what does the nurse anticipate the liver will do?
- A. Cease function and shunt blood to the heart and lungs.
- B. Convert glycogen to glucose for immediate use.
- C. Produce a toxic by-product in relation to stress.
- D. Maintain a basal rate of functioning.
Correct Answer: B
Rationale: When the body is under stress, the sympathetic nervous system is activated to ready the body for action. The effect of the body is to mobilize stored glycogen to glucose to provide additional energy for body action.
You may also like to solve these questions
The nurse is assessing the client's pupils following a sports injury. Which assessment finding(s) indicates a neurologic concern? Select all that apply.
- A. Unequal pupils
- B. Pupil reaction quick
- C. Pinpoint pupils
- D. Absence of pupillary response
- E. Pupil reacts to light
Correct Answer: A,C,D
Rationale: Normal assessment findings include the pupils being equal and reactive to light. Pupils that are unequal, pinpoint in nature, or fail to respond indicate a neurologic impairment.
A nurse is caring for a client with an injury to the central nervous system. When caring for a client with a spinal cord insult that is slowing transmission of the motor neurons, in what would the nurse anticipate a delayed reaction?
- A. Identification of information due to slowed passages of information to brain.
- B. Cognitive ability to understand relayed information.
- C. Processing information transferred from the environment.
- D. Response due to interrupted impulses from the central nervous system
Correct Answer: D
Rationale: The central nervous system is composed of the brain and the spinal cord. Motor neurons transmit impulses from the central nervous system. Slowing transmission in this area would slow the response of transmission leading to a delay in reaction. Sensory neurons transmit impulses from the environment to the central nervous system, allowing identification of a stimulus. Cognitive centers of the brain interpret the information.
The nurse is assessing the assigned client's level of consciousness during morning rounds. The nurse speaks the client's name, strokes the client's hand, and moves the client's shoulder. There is a delay, and then the client states, 'What do you want?' Which level of consciousness should the nurse document?
- A. Conscious
- B. Semicomatose
- C. Somnolent
- D. Stuporous
Correct Answer: C
Rationale: Somnolent or lethargy means that the client is drowsy or sleepy at inappropriate times. This is an improvement from the stuporous state, which includes arousing the client only with vigorous and repeated stimulation. A client that is conscious is alert and responds to stimulation immediately. A client is documented as semicomatose when the client only responds to superficial, relatively mild, painful stimuli.
The nurse is caring for a client who is undergoing single-photon emission computed tomography (SPECT). What is a potential side effect that this client may suffer?
- A. Headache and pain in the neck
- B. Claustrophobia
- C. Allergic reaction to the imaging material
- D. Allergic reaction to radioactive rays
Correct Answer: C
Rationale: SPECT obtains images of the brain after the client intravenously receives radiopharmaceuticals and radioisotopes approximately 1 hour before the test begins. A potential risk of SPECT is the client's allergic reaction to the imaging material. Headache is an aftereffect of a cisternal puncture, and claustrophobia is experienced by clients during a magnetic resonance imaging scan.
The nurse provides care for a client with a deteriorating neurologic status. The nurse collects data at the beginning of the shift that reveals a falling blood pressure (BP) and heart rate (HR), and the client makes no motor response to stimuli. Which documentation of neuromuscular status is most appropriate?
- A. Flaccidity
- B. Abnormal posture
- C. Weak muscular tone
- D. Decorticate posturing
Correct Answer: A
Rationale: The nurse should document flaccidity when the client makes no motor response to stimuli. Clients with impaired cerebral function manifest abnormal posturing, which is documented by the nurse as either decorticate posturing (decorticate rigidity), a position in which the arms are flexed, fists are clenched, and the legs are extended or decerebrate posturing (decerebrate rigidity), when the extremities are stiff and rigid. Muscle tone is documented using a scale of 0 to 5; therefore, weak muscular tone is not the most appropriate documentation.