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. Such an assessment helps in determining the level of assistance the client will need and ensures the safety of both the client and the nurse.

A. Helping the client to sit at the edge of the bed allows them to acclimate to being upright, assess their readiness to stand, and ensures their safety before attempting to walk. However, it is not the priority.

C. After assisting the client to a sitting position at the edge of the bed and assessing their readiness, the nurse can proceed to help the client into a standing position. However, it is not the priority.

D. This option may be necessary if the client requires two-person assistance due to their condition, mobility status, or safety concerns. However, asking for assistance typically comes after assessing the client's readiness and ensuring they are positioned correctly for ambulation.

A. Confusion B. Apnea C. Cyanosis D. Dysrhythmias

Correct Answer is A

Explanation

A. Confusion can be an early sign of hypoxia, especially when oxygen delivery to the brain is compromised. Inadequate oxygenation can affect cognitive function and mental status, leading to confusion. This occurs because the brain is highly sensitive to changes in oxygen levels.

B. Apnea refers to the absence of breathing. While severe hypoxia can lead to respiratory arrest and apnea, it is not typically an early manifestation of hypoxia. Early hypoxia is characterized by attempts to increase ventilation to compensate for decreased oxygen levels, rather than complete cessation of breathing.

C. Cyanosis occurs when there is a bluish discoloration of the skin and mucous membranes due to deoxygenated hemoglobin in the blood. Cyanosis is a late sign of hypoxia and usually indicates significant oxygen deprivation. It is not typically seen in early hypoxia stages.

DDysrhythmias (irregular heart rhythms) can occur as a result of hypoxia, especially if the heart muscle is not receiving enough oxygen. However, dysrhythmias are generally considered a later manifestation of hypoxia, as the heart attempts to compensate for decreased oxygen delivery.

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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

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