The nurse is taking care of a client who has been in the ...

[K@]

The nurse is taking care of a client who has been in the intensive care unit (ICU) for 10 days. Which nursing action would cause a decrease in stimulation of the reticular activating system?
 
  1. Keeping the door closed and the lights dim
  2. Assisting with bathing and activities for elimination
  3. Allowing family members, including children, to visit
  4. Turning on the television

Question 2

The client is receiving a medication that alters the utilization of glutamate, therefore risking an increase in glutamate levels in the CNS. The nurse should evaluate for which manifestation of high glutamate levels?
 
  1. Blurred vision and dry mouth
  2. Signs of neurotoxicity
  3. Ataxia
  4. Tremors

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Answer to Question 1

Correct Answer: 1
Rationale 1: Stimulation of the reticular formation causes heightened alertness and arousal of the brain as a whole. Inhibition causes general drowsiness and the induction of sleep. The RAS is responsible for sleeping and wakefulness, and it performs an alerting function for the cerebral cortex.
Rationale 2: Movement needed for bathing would increase stimulation.
Rationale 3: Allowing visitors would increase stimulation.
Rationale 4: Turning on the TV would increase stimulation.
Global Rationale: Stimulation of the reticular formation causes heightened alertness and arousal of the brain as a whole. Inhibition causes general drowsiness and the induction of sleep. The RAS is responsible for sleeping and wakefulness, and it performs an alerting function for the cerebral cortex. Movement needed for bathing would increase stimulation. Allowing visitors would increase stimulation. Turning on the TV would increase stimulation.

Answer to Question 2

Correct Answer: 2
Rationale 1: Blurred vision and dry mouth are common side affects of anticholinergic drugs.
Rationale 2: High amounts of glutamate can cause death of neurons, and can be the mechanism responsible for certain types of neurotoxicity.
Rationale 3: Ataxia can be a side affect of medications affecting areas of the brain that regulate coordinated movement.
Rationale 4: Tremors are occasionally a side effect of antiseizure medications.
Global Rationale: High amounts of glutamate can cause death of neurons, and can be the mechanism responsible for certain types of neurotoxicity. Blurred vision and dry mouth are common side affects of anticholinergic drugs. Ataxia can be a side affect of medications affecting areas of the brain that regulate coordinated movement. Tremors are occasionally a side effect of antiseizure medications.

[K@]

Excellent

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