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.)

Increased heart rate

Decrease in urinary bladder muscle tone

Increased blood pressure

Decreased salivation

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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Correct Answer is C

Explanation

A. Take the medication in the morning to prevent insomnia: This instruction is not directly

related to minimizing anticholinergic effects; it's more about managing the timing of medication administration.
B. Use cooling measures to decrease fever: Anticholinergic effects do not typically cause fever, so this instruction is not relevant.
C. Chew sugarless gum to moisten the mouth: Anticholinergic medications can cause dry mouth (xerostomia), and chewing gum can stimulate saliva production, alleviating this side effect.
D. Take an antacid to relieve nausea: Anticholinergic effects can include nausea, but taking an antacid is not a specific strategy for managing this side effect.

A. Dantrolene injection, a skeletal muscle relaxant B. Cardiopulmonary resuscitation (CPR) and intubation C. An anticholinesterase drug, such as neostigmine D. Naltrexone hydrochloride injection, an opioid reversal drug

Correct Answer is A

Explanation

A. Dantrolene injection, a skeletal muscle relaxant: The patient is exhibiting signs of malignant hyperthermia, a potentially life-threatening complication of anesthesia. Dantrolene is the primary treatment for malignant hyperthermia as it acts as a skeletal muscle relaxant, reducing muscle rigidity and hypermetabolism associated with the condition.
B. Cardiopulmonary resuscitation (CPR) and intubation: While the patient is experiencing significant physiological distress, initiating CPR and intubation would be premature without first addressing the underlying cause, which appears to be malignant hyperthermia.
C. An anticholinesterase drug, such as neostigmine: Anticholinesterase drugs like neostigmine are not indicated for the treatment of malignant hyperthermia.
D. Naltrexone hydrochloride injection, an opioid reversal drug: Naltrexone is used for opioid overdose reversal and is not appropriate for the treatment of malignant hyperthermia.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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