Chapter 21: The Neurologic System deWit: Medical-Surgical Nursing: Concepts & Practice, 3rd EditionMULTIPLE CHOICE1. The nurse is caring for the patient who has had an injury to the hypothalamus. Which intervention is most important for the nurse to implement? a. Closely control room temperature.b. Monitor for signs of hemorrhage.c. Protect the patient’s eyes from bright lights.d. Turn the patient hourly to maintain skin integrity.ANS: A
The hypothalamus regulates body temperature; therefore, it is important to maintain adequate temperature control of the environment since the body’s ability to regulate the temperature will be affected by injury to the organ. Bleeding, photophobia, and skin integrity are not issues associated with the hypothalamus.PTS: 1 DIF: Cognitive Level: Application REF: 473, Table 21-1 OBJ: 6 (theory) TOP: Hypothalamus KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 2. The nurse differentiates the sympathetic from the parasympathetic nervous systems. Which statement about the sympathetic system is accurate?
The sympathetic nervous system “gears up”the body for “fight or flight”situations with epinephrine that will raise the blood pressure (BP), reduce bowel motility, and energize the whole body to defend itself in a stressful situation. The parasympathetic system slows the heart rate after stress, supports deep sleep, and relaxes blood vessels.PTS: 1 DIF: Cognitive Level: Knowledge REF: 475, Table 21-3 OBJ: 2 (theory) TOP: Sympathetic Nervous System KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. The nurse is assessing an 80-year-old patient. The nurse correctly attributes the slowed knee jerk reflex with which age-related change?