Study Guide for Fundamentals of Nursing The Art and Science of Nursing Care

CHAPTER 35

PREPARING FOR NCLEX

MULTIPLE CHOICE QUESTIONS

1.c 2.d 3.a 4.d 5.a

6.c 7.b 8.d 9.a 10.c

11.d 12.b 13.b 14.d 15.c

16.b 17.c

ALTERNATE-FORMAT QUESTIONS

Multiple Response Questions

1.a, c, d

2.c, e, f

3.b, d, e

4.b, c, d

5.a, e, f

6.c, d, e

DEVELOPING YOUR KNOWLEDGE BASE

FILL-IN-THE-BLANKS

1.Nociceptive

2.Cutaneous

3.Visceral

4.Allodynia

5.Referred

MATCHING EXERCISES

1.e 2.k 3.f 4.j 5.a

6.c 7.g 8.b 9.d 10.h

11.c 12.d 13.b 14.a 15.c

16.a 17.b 18.c 19.j 20.b

21.d 22.k 23.a 24.i 25.c

26.f 27.h 28.g

SHORT ANSWER

1.See table below. Sample answers:

Situation A: Pain, acute migraine, related to unre-

lieved stress as manifested by furrowed brows,

nausea, and anxiety

Situation B: Pain related to animal scratch and

fear, as manifested by pulling back from cat,

swelling and redness around scratch, and exag-

gerated weeping

Situation C: Pain, acute postoperative, related to

cesarean section as manifested by refusal to

move, muscle tension, and rigidity and

helplessness

Situation D: Chronic pain related to degenerative

joint disease as manifested by grimacing, refusal

to walk, increased blood pressure, and exagger-

ated restlessness

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing:

392 ANSWER KEY

Situation Behavioral Physiological Affective

A Furrowed brows Nausea Anxiety

B Crying Swelling and redness on scratched area Fear

C Refusal to move Muscle tension, rigidity Helplessness

D Grimacing, refusal to walk Increased blood pressure Exaggerated restlessness

2.The injured tissue releases chemicals that excite

nerve endings. A damaged cell releases histamine,

which excites nerve endings. Lactic acid accumu-

lates in tissues injured by lack of blood supply and

is believed to excite nerve endings and cause pain

or lower the threshold of nerve endings to other

stimuli. Bradykinin, prostaglandins, and substance

P are also released.

3.Referred pain can be transmitted to a cutaneous site

different from where it originated because afferent

neurons enter the spinal cord at the same level as the

cutaneous site to which the pain has been referred.

4.The gate control theory states that small-diame-

ter nerve fibers conduct excitatory pain stimuli

toward the brain, but nerve fibers of a large

diameter inhibit the transmission of pain

impulses from the spinal cord to the brain. A

gating mechanism is believed to be located in

the substantia gelatinosa of the dorsal horn of

the spinal cord. The “gate” is believed to be

capable of comparing the strength of excitatory

and inhibitory signals entering this region to

determine which impulses will travel toward

the brain. When too much information arrives

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