The patient has been exposed to a nerve agent. For which symptoms will the nurse most likely assess?
1. Salivation, involuntary urination, and convulsions
2. Dilated pupils and increased blood pressure and heart rate
3. Pinpoint pupils, decreased blood pressure, and increased heart rate
4. Rapid breathing and cold, clammy skin
1
Rationale 1: Symptoms of nerve gas exposure are related to overstimulation of acetylcholine and can result in salivation, involuntary urination, and convulsions. The nerve agent blocks acetylcholinesterase.
Rationale 2: Dilated pupils and increased blood pressure and heart rate are symptoms of sympathetic nervous system stimulation.
Rationale 3: Pinpoint pupils, decreased blood pressure, and increased heart rate are not symptoms of overstimulation of acetylcholine.
Rationale 4: Rapid breathing and cold, clammy skin are not symptoms of overstimulation of acetylcholine.
Global Rationale: Symptoms of nerve gas exposure are related to overstimulation of acetylcholine and can result in salivation, involuntary urination, and convulsions. The nerve agent blocks acetylcholinesterase. Dilated pupils and increased blood pressure and heart rate are symptoms of sympathetic nervous system stimulation. Pinpoint pupils, decreased blood pressure, and increased heart rate are not symptoms of overstimulation of acetylcholine. Rapid breathing and cold, clammy skin are not symptoms of overstimulation of acetylcholine.
You might also like to view...
A nurse works in a very remote area and is interested in discovering how telehealth services might improve local health care. What action by the nurse is best?
a. Conduct a survey of residents on the potential use of telehealth. b. Interview providers where telehealth is already in use. c. Perform a literature search on the topic of telehealth. d. Visit the website of the closest telehealth resource center (TRC).
The oncology nurse assessing a patient with Rai stage II chronic lymphocytic leukemia (CLL) will most likely find:
A) lymphocytosis and no enlargement of the lymph nodes, spleen, or liver. B) lymphocytosis, an enlarged spleen, and possibly an enlarged liver. C) lymphocytosis, anemia, and possibly an enlarged spleen or liver. D) lymphocytosis, thrombocytopenia, and possibly anemia, enlarged lymph nodes, spleen, or liver.
After obtaining the patient's specimen, take it to the nurses' station for labeling
True False
Alterations in which part of the brain are linked to hallucinations, delusions, and thought disorders associated with schizophrenia?
a. Parietal lobe b. Limbic system c. Temporal lobe d. Hypothalamus