A client who has had a right-sided below-the-knee amputation is complaining of constant pain in his right ankle. The nurse documents that the client is experiencing what type of pain?

Intractable

Radiating

Phantom

Referred

Answer and Explanation

The Correct Answer is C

A. Intractable pain refers to pain that is severe and persistent, difficult to control or manage despite treatment. It may be constant or intermittent but is generally not specific to a body part that has been amputated. Intractable pain is not typically used to describe pain specifically related to a phantom limb or residual limb pain after amputation.

B. Radiating pain is pain that spreads from its origin to another location in the body. It often follows the path of a nerve and can be associated with nerve compression or irritation. While radiating pain can occur in various conditions, it does not specifically describe the type of pain experienced in an amputated limb.

C. Phantom pain is perceived pain that feels like it is coming from a part of the body that has been amputated. It is a common phenomenon after limb amputation where the brain continues to receive pain signals from nerves that originally innervated the missing limb. Phantom pain is the correct term for the pain experienced by a client with a below-the-knee amputation who complains of pain in the right ankle. It is described as constant pain in the missing limb or part.

D. Referred pain is pain perceived at a location other than the site of the painful stimulus or origin. It occurs because of shared neural pathways between different areas of the body. Referred pain is not typically used to describe pain specifically related to amputation or phantom limb pain.

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Correct Answer is B

Explanation

B. This is the initial phase of the nurse-client relationship where the individuals first meet. It is characterized by establishing rapport, clarifying roles, setting goals, and developing an agreement or contract for the relationship.

A. This phase occurs towards the end of the nurse-client relationship when goals have been achieved or the relationship is ending for other reasons. It involves summarizing, evaluating progress, and saying goodbye.

C. This phase follows the orientation phase. It is characterized by actively working together to achieve mutually agreed upon goals. During this phase, the nurse and client explore issues, develop and implement solutions, and evaluate progress towards goals.

D. This phase occurs before the nurse and client meet formally. It involves gathering information about the client from various sources, such as medical records or other healthcare professionals.

A. staff to family members. B. hospital environment to family members. C. family members to client. D. client to family members.

Correct Answer is C

Explanation

C. This option correctly identifies therationale behind the nurse's instruction. Immunosuppressed clients have a weakened immune system, making them highly vulnerable to infections. Family members may carry microorganisms on their hands, clothes, or respiratory secretions that can potentially transmit infections to the client. Wearing gloves and a mask helps reduce the risk of introducing pathogens to the client.

A. This option suggests that the risk is related to hospital staff transmitting infections to family members. While this is a concern in healthcare settings, it is not directly related to the specific situation described where family members are visiting an immunosuppressed client in a protective environment.

B. This option implies that the hospital environment itself poses a risk of infection transmission to family members. While hospitals can harbor various pathogens, the primary concern in this scenario is the transmission of infections to the immunosuppressed client from outside sources, including family members.

D. This option suggests that the client could transmit infections to family members. While this is theoretically possible depending on the specific infectious agent and the client's condition, the primary concern in a protective environment is preventing infections from entering the client's environment and affecting their health.

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A client who has had a right-sided below-the-knee amputation is complaining of constant pain in his right ankle. The nurse documents that the client is experiencing what type of pain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The phase of the nurse-client relationship that begins when the individuals first meet, and that is characterized by an agreement to continue meeting and assessing needs is the:

Correct Answer is B

Explanation

The nurse is instructing family members of an immunosuppressed client who has been placed in a protective environment to wear gloves and a mask when visiting the client. The nurse is aware that this practice is important to prevent infection transmission from:

Correct Answer is C

Explanation

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