The nurse assess that the patient is having a sympathetic response when noting what manifestation?
Decrease in heart rate and perfusion, and an increase in inflammatory response
Increase motility and secretion in the GI tract, constriction of bronchi and pupils
Increase in blood pressure, bronchodilation, and decrease bowel sounds
Decrease in sweating, decrease in respiration, and pupil constriction
The Correct Answer is C
A) Decrease in heart rate and perfusion, and an increase in inflammatory response: These manifestations suggest parasympathetic nervous system activation, not the sympathetic response. The sympathetic system generally increases heart rate and perfusion to support "fight or flight" responses. Additionally, inflammatory responses are more immune-related and are not a direct effect of sympathetic activation.
B) Increase motility and secretion in the GI tract, constriction of bronchi and pupils: This is characteristic of parasympathetic nervous system activity. The parasympathetic system stimulates digestion (increased motility and secretion) and causes bronchoconstriction and pupil constriction (miosis). The sympathetic nervous system, in contrast, inhibits GI motility and causes bronchodilation and pupil dilation.
C) Increase in blood pressure, bronchodilation, and decrease bowel sounds: These are hallmark signs of sympathetic nervous system activation. When the sympathetic system is activated during stress or danger, it leads to vasoconstriction, which increases blood pressure. Bronchodilation occurs to allow more oxygen intake, and GI motility decreases (manifested as reduced bowel sounds) to redirect energy to more vital functions, like increased circulation to muscles.
D) Decrease in sweating, decrease in respiration, and pupil constriction: These signs suggest parasympathetic or a relaxed state. The sympathetic nervous system typically increases sweating, respiration, and causes pupil dilation to prepare the body for increased activity. Decreased sweating and respiration, along with pupil constriction, would not be consistent with the sympathetic response.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Breath sounds: Prior to administering Atrovent (Ipratropium Bromide), it is essential for the nurse to assess the child’s breath sounds. Ipratropium is an anticholinergic medication used to relieve bronchospasm in conditions like asthma or chronic obstructive pulmonary disease (COPD). By evaluating breath sounds, the nurse can assess the severity of the respiratory condition and monitor for any wheezing or crackles, which may indicate the need for further intervention or adjustment of the treatment.
B) Cardiac disorders: While some caution may be warranted in patients with cardiac disorders when using certain medications (e.g., sympathomimetics), Ipratropium Bromide is an anticholinergic agent that primarily affects the respiratory system. It is not directly contraindicated in children with cardiac disorders, so assessing for cardiac conditions is not the most critical initial assessment when administering this drug.
C) Recent injuries: Recent injuries do not specifically relate to the need for assessment prior to administering Ipratropium. This medication targets the lungs and airways, so assessing for recent injuries would not be as pertinent unless the injuries impacted the child’s ability to breathe (e.g., rib fractures, lung trauma).
D) Hypertension: Hypertension is not a primary concern when administering Ipratropium Bromide. While anticholinergic drugs should be used cautiously in certain individuals (e.g., those with glaucoma or urinary retention), hypertension is not a contraindication for this medication. It would be more critical to assess for respiratory status, particularly breath sounds, to evaluate the efficacy of the treatment.
Correct Answer is C
Explanation
A) Central nervous system (CNS), memory, and cognition: Myasthenia gravis (MG) primarily affects the neuromuscular junction, causing muscle weakness, not directly the central nervous system. While cognitive function may be affected in some patients due to fatigue or medication side effects, it is not the main system affected by MG.
B) Cardiovascular system and postural muscles: Myasthenia gravis primarily affects skeletal muscles, especially those responsible for voluntary movements like facial muscles, swallowing, and respiratory muscles. While MG can lead to general weakness, it does not typically affect the cardiovascular system directly.
C) Respiratory system and facial muscles: This is the correct answer. Myasthenia gravis primarily affects the voluntary muscles, particularly those controlling eye movements, facial expressions, swallowing, and breathing. The respiratory system is vulnerable due to weakness of the diaphragm and intercostal muscles, which can lead to respiratory distress in severe cases. Facial muscles are commonly affected, leading to symptoms like ptosis (drooping eyelids) and difficulty smiling or speaking.
D) Gastrointestinal system (GI) and lower extremity muscles: Although myasthenia gravis can cause generalized muscle weakness, it is not typically associated with the gastrointestinal system. The primary impact is on the voluntary muscles, such as those in the face, throat, and respiratory system. Lower extremity muscles can be affected, but the respiratory and facial muscles are more commonly involved.
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