[Ex4] - C15 - AP

Question 1

15-1. A patient asks the nurse where nociceptors can be found. How should the nurse respond? One
location in which nociceptors can be found is the:

a. skin.
b. spinal cord.
c. efferent pathways.
d. hypothalamus.

Answer 1

ANS: A

Nociceptors are pain receptors and can be found in the skin. Nociceptors are not located in the
spinal cord. Nociceptors are not located in efferent, but afferent, pathways. Nociceptors are
not located in the hypothalamus but can be found in the meninges.

Question 2

15-2. A nurse is discussing an individual’s conditioned or learned approach or avoidance behavior
in response to pain. Which system is the nurse describing?

a. Sensory-discriminative system
b. Affective-motivational system
c. Sensory-motivational system
d. Cognitive-evaluative system

Answer 2

ANS: B

The affective-motivational system determines an individual’s conditioned avoidance
behaviors and emotional responses to pain. The sensory-discriminative system is mediated by
the somatosensory cortex and is responsible for identifying the presence, character, location,
and intensity of pain. The sensory-motivational system is not a system in the response to pain.
The cognitive-evaluative system overlies the individual’s learned behavior concerning the
experience of pain and can modulate perception of pain.

Question 3

15-3. A patient scrapes both knees while playing soccer and reports sharp and well-localized pain.
Which of the following should the nurse document to most accurately characterize the pain?

a. Chronic pain
b. Referred pain
c. Somatic pain
d. Visceral pain

Answer 3

ANS: C

Somatic pain is superficial, arising from the skin. It is typically well localized and described
as sharp, dull, aching, or throbbing. Chronic pain has been defined as lasting for more than
3–6 months. Referred pain is felt in an area removed or distant from its point of origin; the
area of referred pain is supplied by the same spinal segment as the actual site of pain. Visceral
pain is pain in internal organs and lining of body cavities and tends to be poorly localized,
with an aching, gnawing, throbbing, or intermittent cramping quality.

Question 4

15-4. A nurse should document on the chart that chronic pain is occurring when the patient reports
the pain has lasted longer than:

a. 1 month.
b. 3–6 months.
c. 1 year.
d. 2–3 years.

Answer 4

ANS: B

Chronic or persistent pain has been defined as lasting for more than 3–6 months.

Question 5

15-5. Several years after an amputation, the patient continues to sporadically feel pain in the absent
hand. What type of pain should the nurse document in the chart?

a. Neuropathic pain
b. Visceral pain
c. Phantom limb pain
d. Chronic pain

Answer 5

ANS: C

The qualities we normally feel from the body, including pain, also can be felt in the absence
of inputs from the body, such as is noted with phantom limb pain. Neuropathic pain is
initiated or caused by a primary lesion or dysfunction in the nervous system. Visceral pain
refers to pain in internal organs and the lining of body cavities. Chronic pain lasts more than
3–6 months and is not associated with loss of a limb.

Question 6

15-6. When planning care for a child in pain, which principle should the nurse remember? The pain
threshold in children is _____ that of adults.

a. higher than
b. more variable
c. the same as
d. not related to

Answer 6

ANS: B

The pain threshold in children is lower than or the same as that of adults.

Question 7

15-7. When the nurse is taking a patient’s temperature, which principle should the nurse remember?
Regulation of body temperature primarily occurs in the:

a. cerebrum.
b. brainstem.
c. hypothalamus.
d. pituitary gland.

Answer 7

ANS: C

Temperature regulation (thermoregulation) is mediated primarily by the hypothalamus, not the
cerebrum, the brainstem, or the pituitary gland.

Question 8

15-8. When the nurse is discussing the patient’s cyclical temperature fluctuation occurring on a
daily basis, what term should the nurse use?

a. Thermogenesis cycle
b. Thermoconductive phases
c. Adaptive pattern
d. Circadian rhythm

Answer 8

ANS: D

Temperature fluctuation is related to circadian rhythm, not the thermogenesis cycle,
thermoconductive phases, or adaptive patterns.

Question 9

15-9. A nurse wants to teach about one of the primary organs responsible for heat production.
Which organ should the nurse include?

a. Pancreas
b. Liver
c. Adrenal medulla
d. Heart

Answer 9

ANS: C

Thyroxine acts on the adrenal medulla, causing the release of epinephrine into the
bloodstream. Epinephrine causes vasoconstriction that increases metabolic rates, thus
increasing heat production. Heat production does not involve the pancreas, the liver, or the
heart.

Question 10

15-10. Heat loss from the body via convection occurs by:

a. evaporation of electromagnetic waves.
b. transfer of heat through currents of liquids or gas.
c. dilation of blood vessels bringing blood to skin surfaces.
d. direct heat loss from molecule-to-molecule transfer.

Answer 10

ANS: B

Convection occurs by transfer of heat through currents of gases or liquids, exchanging warmer
air at the body’s surface with cooler air in surrounding spaces. Convection does not involve
electromagnetic waves, bringing blood to skin surfaces, or molecule-to-molecule transfer.

Question 11

15-11. For evaporation to function effectively as a means of dissipating excess body heat, which one
of the following conditions must be present?

a. Moisture
b. Fever
c. Pyrogens
d. Trauma

Answer 11

ANS: A

Moisture must be present because heat is lost through evaporation from the surface of skin
and lining of mucous membranes, a major source of heat reduction connected with increased
sweating in warmer surroundings. Fever is not required for evaporation to occur, but moisture
is. Pyrogens are heat producers and do not assist with evaporation, but moisture is required.
Trauma is not a portion of the evaporative process of heat loss.

Question 12

15-12. A patient received a prescription for a weight loss pill. One effect of the pills is to increase the
release of epinephrine. Which of the following would be expected to also occur?

a. Decreased vascular tone
b. Increased skeletal muscle tone
c. Increased heat production
d. Decreased basal metabolic rate

Answer 12

ANS: C

Epinephrine causes vasoconstriction, stimulates glycolysis, and increases metabolic rate, thus
increasing secondary heat production. Epinephrine does not lead to decreased vascular tone or
increased skeletal muscle tone but does increase metabolic rate.

Question 13

15-13. When a patient has a fever, which of the following thermoregulatory mechanisms is
activated?

a. The body’s thermostat is adjusted to a lower temperature.
b. Temperature is raised above the set point.
c. Bacteria directly stimulate peripheral thermogenesis.
d. The body’s thermostat is reset to a higher level.

Answer 13

ANS: D

Fever (febrile response) is a temporary “resetting of the hypothalamic thermostat” to a higher
level in response to endogenous or exogenous pyrogens. Fever is the result of the body’s
attempt to raise temperature, not adjust it to a lower level. When fever occurs, the temperature
is raised, but the rise is due to a reset of the thermostat. Bacteria do not stimulate peripheral
thermogenesis, but their endotoxins do.

Question 14

15-14. Exogenous pyrogens are:

a. interleukins.
b. endotoxins.
c. prostaglandins.
d. corticotropin-releasing factors.

Answer 14

ANS: B

Exogenous pyrogens are endotoxins produced by pathogens. They are not interleukins,
prostaglandins, or corticotropin-releasing factors.

Question 15

15-15. Hikers are attempting to cross the Arizona desert with a small supply of water. The
temperatures cause them to sweat profusely and become dehydrated. The hikers are
experiencing:

a. heat cramping.
b. heat exhaustion.
c. heat stroke.
d. malignant hyperthermia.

Answer 15

ANS: B

Heat exhaustion results from prolonged high core or environmental temperatures, which cause
profound vasodilation and profuse sweating, leading to dehydration, decreased plasma
volumes, hypotension, decreased cardiac output, and tachycardia. Symptoms include
weakness, dizziness, confusion, nausea, and fainting. Heat cramping is severe, spasmodic
cramps in the abdomen and extremities that follow prolonged sweating and associated sodium
loss. Heat cramping usually occurs in those not accustomed to heat or those performing
strenuous work in very warm climates. Heat stroke is a potentially lethal result of an
overstressed thermoregulatory center. With very high core temperatures (>40° C; 104° F), the
regulatory center ceases to function, and the body’s heat loss mechanisms fail. Malignant
hyperthermia is a potentially lethal complication of a rare inherited muscle disorder that may
be triggered by inhaled anesthetics and depolarizing muscle relaxants.

Question 16

15-16. What is the physiologic response when the body’s core temperature is altered due to
prolonged exposure to a cold environment?

a. Increased respirations
b. Ischemic tissue damage
c. CNS excitation
d. Increased cellular metabolism

Answer 16

ANS: B

Hypothermia (marked cooling of core temperature) produces depression of the central nervous
and respiratory systems, vasoconstriction, alterations in microcirculation, coagulation, and
ischemic tissue damage. Hypothermia does not lead to increased respirations, CNS excitation,
or increased cellular metabolism.

Question 17

15-17. Which finding indicates the patient is having complications from heat stroke?

a. Mild elevation of core body temperatures
b. Cerebral edema and degeneration of the CNS
c. Spasmodic cramping in the abdomen and extremities
d. Alterations in calcium uptake

Answer 17

ANS: B

Symptoms of heat stroke include high core temperature, absence of sweating, rapid pulse,
confusion, agitation, and coma, and complications include cerebral edema and degeneration of
the CNS. Neither cramping nor alterations in calcium uptake are considered complications of
a heat stroke.

Question 18

15-18. Which condition would be treated with therapeutic hypothermia?

a. Malnutrition
b. Hypothyroidism
c. Reimplantation surgery
d. Parkinson disease

Answer 18

ANS: C

Therapeutic hypothermia is seen with reimplantation surgery, not malnutrition,
hypothyroidism, or Parkinson disease.

Question 19

15-19. A patient is undergoing a sleep lab test. When the sleep lab worker notices EEG patterns with
brain activity similar to the normal awake pattern, which phase of sleep is occurring?

a. Non–rapid eye movement (REM)
b. Fast wave
c. REM
d. Delta wave

Answer 19

ANS: C

REM sleep is called paradoxical sleep because the EEG pattern is similar to the normal awake
pattern and the brain is very active with dreaming. Neither non-REM, fast wave sleep, nor
delta wave sleep produces EEG patterns similar to the normal awake pattern.

Question 20

15-20. Most memorable dreams occur during which sleep phase?

a. Non-REM
b. Alpha wave
c. REM
d. Delta wave

Answer 20

ANS: C

Dreams occur during REM sleep. Dreams are not associated with non-REM, alpha wave, or
delta wave sleep.

Question 21

15-21. During the sleep cycle, when does loss of temperature control occur?

a. Non-REM sleep
b. Light sleep
c. REM sleep
d. Delta wave sleep

Answer 21

ANS: C

Loss of temperature control occurs during REM sleep. Loss of temperature control is not
associated with non-REM sleep, light sleep, or delta wave sleep.

Question 22

15-22. A 52-year-old male enters a sleep study to gather information about his sleep disturbances. He
reports that his wife will not let him sleep in the bed with her until he stops snoring so loudly.
He also reports feeling tired a lot through the day. When the nurse checks the chart, what is
the most likely diagnosis?

a. Insomnia
b. Obstructive sleep apnea syndrome (OSAS)
c. Somnambulism
d. Jet-lag syndrome

Answer 22

ANS: B

OSAS generally results from upper airway obstruction recurring during sleep with excessive
snoring and multiple apneic episodes that last 10 seconds or longer. Insomnia is the inability
to fall or stay asleep and may be mild, moderate, or severe. It does not involve snoring.
Somnambulism is sleep-walking. Jet-lag syndrome is a disorder of waking and sleeping and
does not involve snoring.

Question 23

15-23. A child suffers from sudden apparent arousals in which she expresses intense fear or other
emotion. Her mother reports that she seems to wake screaming, but that she is difficult to
waken completely. The child most likely suffers from:

a. night terrors.
b. parasomnia.
c. somnambulism.
d. enuresis episodes.

Answer 23

ANS: A

Night terrors are characterized by sudden apparent arousals in which the child expresses
intense fear or emotion. Parasomnia is unusual behaviors during sleep. Somnambulism is
sleep-walking. Enuresis episodes are bed-wetting.

Question 24

15-24. The ophthalmologist is teaching about the structure of the eye that prevents light from
scattering in the eye. What structure is the ophthalmologist describing?

a. Iris
b. Pupil
c. Choroid
d. Retina

Answer 24

ANS: C

The choroid is the deeply pigmented middle layer that prevents light from scattering inside the
eye. The iris is a part of the choroid and contains the pupil, which lets light into the eye. The
retina is the innermost layer of the eye.

Question 25

15-25. A 50-year-old diabetic patient experiences visual disturbances and decides to visit his primary
care provider. After examination, the primary care provider tells the patient that the cells that
allow him to see are degenerated. Which of the following structures is most likely damaged?

a. Lens
b. Pupil
c. Cornea
d. Retina

Answer 25

ANS: D

The retina is the innermost layer of the eye, converting light energy into nerve impulses.
Light entering the eye is focused on the retina by the lens. The pupil allows light to enter the
eye. The cornea is the portion of the sclera in the central anterior region that allows light to
enter the eye.

Question 26

15-26. A young child presents to the ophthalmologist for visual difficulties secondary to eye
deviation. One of the child’s eyes deviates inward, thereby decreasing the visual field. Which
of the following diagnoses is most likely?

a. Entropia
b. Extropia
c. Diplopia
d. Nystagmus

Answer 26

ANS: A

The deviation of the eye inward is entropia while deviation of the eye outward is extropia.
Diplopia is double vision. Nystagmus is an involuntary unilateral or bilateral rhythmic
movement of the eyes.

Question 27

15-27. A patient has increased intraocular pressure. Which diagnosis will the nurse observe on the
chart?

a. Glaucoma
b. Ocular degeneration
c. Diplopia
d. Nystagmus

Answer 27

ANS: A

Glaucoma is the result of increased intraocular pressure. Ocular degeneration results in
changes in vision but not intraocular pressure. Diplopia is double vision. Nystagmus is an
involuntary unilateral or bilateral rhythmic movement of the eyes.

Question 28

15-28. A 70-year-old patient presents to the primary care provider reporting loss of vision. A history
that includes hypertension and cigarette smoking supports which visual diagnosis?

a. Presbyopia
b. Macular degeneration
c. Strabismus
d. Amblyopia

Answer 28

ANS: B

Age-related macular degeneration (AMD) is a severe and irreversible loss of vision and a
major cause of blindness in older individuals. Hypertension and cigarette smoking are risk
factors. Presbyopia is a condition associated with aging in which the patient experiences
reduced near vision. In strabismus, one eye deviates from the other when the person is looking
at an object. In amblyopia, vision is reduced in the affected eye caused by cerebral blockage
of the visual stimuli.

Question 29

15-29. Which group of people is most prone to color blindness?

a. Males
b. Females
c. Elderly persons
d. Children

Answer 29

ANS: A

Color blindness, present most often in males, affects 8% of the male population and 0.5% of
the female population. Neither the elderly nor children are most prone to color blindness.

Question 30

15-30. A nurse is teaching about the structure that connects the middle ear with the pharynx. Which
structure is the nurse describing?

a. Organ of Corti
b. Eustachian tube
c. Semicircular canal
d. Auditory canal

Answer 30

ANS: B

The Eustachian tube connects the middle ear to the pharynx. The organ of Corti contains the
hair cells. The semicircular canal is one of the three bones of the labyrinth. The auditory canal
leads to the middle ear.

Question 31

15-31. The most common form of sensorineural hearing loss in the elderly is:

a. conductive hearing loss.
b. acute otitis media.
c. presbycusis.
d. Ménière disease.

Answer 31

ANS: C

Presbycusis is the most common form of sensorineural hearing loss in elderly people.
Conductive hearing loss does not occur as frequently as presbycusis. Otitis media is an
infection in the middle ear and is not defined as a hearing loss. Ménière disease leads to
vertigo, not hearing loss.

Question 32

15-32. A 15 year old is diagnosed with an outer ear infection. Which of the following is most likely
to cause this infection?

a. Haemophilus
b. Streptococcus pneumonia
c. Moraxella catarrhalis
d. Escherichia coli

Answer 32

ANS: D

The most common causes of acute infections are bacterial microorganisms including
Pseudomonas, E. coli, and Staphylococcus aureus.

Question 33

15-33. The nurse would expect the patient with an alteration in proprioception to experience vertigo,
which is manifested by:

a. headache.
b. light sensitivity.
c. a sensation that the room is spinning.
d. loss of feeling in the lips.

Answer 33

ANS: C

Alterations in proprioception are manifested by a sensation that the room is spinning, not
headache, light sensitivity, or loss of feeling in the lips.

Question 34

15-34. Which system modulates a patient’s perception of pain?

a. Sensory-discriminative system
b. Affective-motivational system
c. Cognitive-evaluative system
d. Reticular-activating system

Answer 34

ANS: C

The cognitive-evaluative system overlies the individual’s learned behavior concerning the
experience of pain and can modulate perception of pain. The sensory-discriminative system is
mediated by the somatosensory cortex and is responsible for identifying the presence,
character, location, and intensity of pain. The affective-motivational system determines an
individual’s conditioned avoidance behaviors and emotional responses to pain. The
reticular-activating system does not play a role in the perception of pain.

Question 35

15-35. A patient asks the nurse how often REM sleep occurs. The nurse responds, “About every
_____ minutes.”

a. 15
b. 30
c. 60
d. 90

Answer 35

ANS: D

REM sleep occurs every 90 minutes.