The nurse is concerned that a patient is experiencing sympathetic ...

[ssal]

The nurse is concerned that a patient is experiencing sympathetic nervous system effects after a head injury. What did the nurse assess to make this clinical decision?
 
  Select all that apply.
 
  1. damp skin
  2. cold extremities
  3. heart rate 68 bpm
  4. deep, rapid respirations
  5. elevated blood pressure

Question 2

The nurse asks a patient who has suffered a cerebral vascular accident (CVA) to complete the heel-to-shin test. What is the nurse testing for with this technique?
 
  1. ataxia
  2. graphesthesia
  3. coordination
  4. spasticity

[recede]

Answer to Question 1

Correct Answer: 1, 2, 4, 5
Stimulation of the sympathetic division exerts effects on target organs or tissues including diaphoresis, leading to damp skin; vasoconstriction of skin blood vessels, leading to cold skin; dilation of the bronchioles, leading to deep rapid respirations; and vasoconstriction of arteries, leading to an elevated blood pressure. A heart rate of 68 would be an effect of the parasympathetic division of the autonomic nervous system.

Answer to Question 2

Correct Answer: 3
The heel-to-shin test requires the patient to run each heel down each shin, while in a supine position. This technique tests the patient's coordination. Ataxia is the inability to walk or difficulty walking. Graphesthesia is the ability to discriminate a number traced on the palm. Spasticity is an increase in muscle tone associated with disease of the corticospinal motor tract and is not tested with the heel-to-shin technique.

[ssal]

Excellent

[patma1981]

TYSM