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The nurse is caring for a client experiencing sympathetic nervous system stimulation. What assessment finding supports this diagnosis? Select all that apply. (Select All that Apply.)

A.

Increased heart rate

B.

Decrease in urinary bladder muscle tone

C.

Increased blood pressure

D.

Decreased salivation

E.

Decreased bowel sounds

Answer and Explanation

Correct Answer : A,C

A.    Increased heart rate: Sympathetic nervous system stimulation typically leads to increased heart rate as part of the "fight or flight" response.
B.    Decrease in urinary bladder muscle tone: Sympathetic stimulation would typically cause relaxation of the urinary bladder, leading to increased muscle tone.
C.    Increased blood pressure: Sympathetic nervous system activation results in vasoconstriction and increased cardiac output, leading to elevated blood pressure.
D.    Decreased salivation: Sympathetic stimulation can lead to decreased salivation as part of the "fight or flight" response, but it's not a consistent finding.
E.    Decreased bowel sounds: Sympathetic activation can inhibit gastrointestinal motility, leading to decreased bowel sounds, but it's not a universal finding in sympathetic stimulation.
 


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Related Questions

Correct Answer is C

Explanation

A. CT of the brain can proceed regardless of atropine administration, as it does not directly affect the assessment of brain stem reflexes.
B. Electroencephalogram (EEG) can also proceed regardless of atropine administration, as it evaluates brain electrical activity rather than brain stem reflexes.
C. Assessment of brain stem reflexes should be postponed until all atropine is excreted and no

longer exerting its effects. Atropine can mask or alter the pupillary response and other brain stem reflexes, such as gag reflex and cough reflex, which are important indicators of neurological function.
D. Pupil response assessment should be postponed until atropine effects have dissipated, as

atropine can cause pupillary dilation, which may interfere with accurate assessment of pupil size and reactivity

Correct Answer is D

Explanation

A. Do slow position changes to avoid falls from lowering blood pressure: This is not the priority teaching point for an anticholinergic medication. While some anticholinergics can cause orthostatic hypotension, the risk of urinary retention is a more significant concern.
B. If you feel short of breath, use a rescue inhaler: This instruction is unrelated to the use of anticholinergic medication and may be more relevant for patients with emphysema.
C. "If possible, try to avoid rooms that are cold.": Avoiding cold rooms is not directly related to the use of anticholinergic medication. The priority teaching point should address potential adverse effects specific to the medication.
D. "Make sure to seek care immediately if you're not able to urinate.": Anticholinergic medications can exacerbate urinary retention, particularly in older adults with benign prostatic hyperplasia. It's crucial for the patient to understand the importance of seeking medical attention if they experience difficulty urinating.

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