Which assessment finding indicates to the nurse that the patient is experiencing difficulty with proprioception?

The patient must hold on to the railing when ambulating in the hallway.

The patient must add extra seasoning to food in order for it to have any flavor.

The patient suffered a first-degree burn when a heating pad was left on too long.

The patient did not smell smoke even though the smoke detector was alarming.

Answer and Explanation

The Correct Answer is A

Choice A reason: This is correct. The patient must hold on to the railing when ambulating in the hallway indicates that the patient is experiencing difficulty with proprioception. Proprioception is the body's ability to sense its own position, movement, and spatial orientation. It helps the patient maintain balance and coordination. If the patient has impaired proprioception, they may feel unsteady or fall when walking without support.

Choice B reason: This is incorrect. The patient must add extra seasoning to food in order for it to have any flavor does not indicate that the patient is experiencing difficulty with proprioception. This may indicate that the patient has a reduced sense of taste, which can be caused by various factors, such as aging, medication, infection, or smoking. It does not affect the patient's perception of their body or movement.

Choice C reason: This is incorrect. The patient suffered a first-degree burn when a heating pad was left on too long does not indicate that the patient is experiencing difficulty with proprioception. This may indicate that the patient has a reduced sense of pain or temperature, which can be caused by nerve damage, diabetes, or spinal cord injury. It does not affect the patient's perception of their body or movement.

Choice D reason: This is incorrect. The patient did not smell smoke even though the smoke detector was alarming does not indicate that the patient is experiencing difficulty with proprioception. This may indicate that the patient has a reduced sense of smell, which can be caused by nasal congestion, allergy, infection, or head injury. It does not affect the patient's perception of their body or movement.

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Correct Answer is B

Explanation

Choice A reason: This is incorrect. The patient frequently using an alcohol-based sanitizer for hand hygiene does not pose a risk for poisoning. Alcohol-based sanitizers are safe and effective for reducing the transmission of germs.

Choice B reason: This is correct. The patient taking acetaminophen 1000 mg every 4 hours around the clock poses a risk for poisoning. Acetaminophen is a common over-the-counter pain reliever that can cause liver damage or failure if taken in excess or for a prolonged period of time. The maximum daily dose of acetaminophen for adults is 4000 mg.

Choice C reason: This is incorrect. The patient taking alprazolam 0.25 mg every 3 hours does not pose a risk for poisoning. Alprazolam is a prescription medication that belongs to the benzodiazepine class of drugs. It is used to treat anxiety and panic disorders. It can cause side effects such as drowsiness, dizziness, or dependence, but not poisoning.

Choice D reason: This is incorrect. The patient rinsing with a fluoride mouthwash after brushing the teeth does not pose a risk for poisoning. Fluoride is a mineral that helps prevent tooth decay and strengthen the enamel. It is added to many dental products and public water supplies. It can cause mild stomach upset if swallowed in large amounts, but not poisoning.

A. Release of prostaglandins lowers the patient’s heart rate and blood pressure. B. Release of substance P narrows the airways and leads to hypoxemia. C. Release of endorphins causes dangerous elevation of blood pressure. D. Stimulation of the sympathetic nervous system will increase cardiac workload.

Correct Answer is D

Explanation

Choice A reason: This is an incorrect choice because release of prostaglandins lowers the patient’s heart rate and blood pressure is not a reason why acute pain is particularly dangerous for a patient having a heart attack. Prostaglandins are inflammatory mediators that are involved in pain perception and modulation, but they do not have a direct effect on the heart rate and blood pressure. In fact, some prostaglandins may have a protective role in the cardiovascular system by preventing platelet aggregation and vasodilation.

Choice B reason: This is an incorrect choice because release of substance P narrows the airways and leads to hypoxemia is not a reason why acute pain is particularly dangerous for a patient having a heart attack. Substance P is a neuropeptide that is involved in pain transmission and modulation, but it does not have a significant effect on the airways or the oxygen level. Substance P may cause bronchoconstriction in some patients with asthma or chronic obstructive pulmonary disease, but this is not a common or serious complication of acute pain.

Choice C reason: This is an incorrect choice because release of endorphins causes dangerous elevation of blood pressure is not a reason why acute pain is particularly dangerous for a patient having a heart attack. Endorphins are endogenous opioids that are involved in pain inhibition and modulation, but they do not have a major effect on the blood pressure. Endorphins may cause a slight increase in blood pressure by activating the opioid receptors in the brainstem, but this is not a significant or harmful response to acute pain.

Choice D reason: This is the correct choice because stimulation of the sympathetic nervous system will increase cardiac workload is a reason why acute pain is particularly dangerous for a patient having a heart attack. The sympathetic nervous system is part of the autonomic nervous system that is responsible for the fight-or-flight response, which is triggered by acute pain. The sympathetic nervous system will increase the heart rate, blood pressure, and cardiac contractility, which will increase the oxygen demand and consumption of the heart. This will worsen the ischemia and injury of the myocardium, and may lead to arrhythmias, heart failure, or cardiac arrest.

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Which assessment finding indicates to the nurse that the patient is experiencing difficulty with proprioception?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment finding leads the nurse to add risk for poisoning to the patient’s care plan?

Correct Answer is B

Explanation

Why is acute pain particularly dangerous for a patient having a heart attack?

Correct Answer is D

Explanation

Which is an example of nociceptive pain?

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