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 Watching exciting or stimulating movies, especially horror movies, before bedtime can hinder sleep onset. Such activities can increase arousal and make it more difficult to relax and fall asleep. This statement suggests a lack of understanding of good sleep hygiene practices. Further teaching is needed to discourage stimulating activities before bedtime.

A. Consistency in sleep schedule helps regulate the body's internal clock (circadian rhythm) and can promote better sleep quality. There is no need for further teaching regarding this statement.

C. This statement reflects good sleep hygiene advice. Getting up and engaging in a quiet, boring activity if unable to fall asleep after about 30 minutes can prevent frustration and anxiety associated with lying awake in bed. This practice helps condition the mind to associate the bed with sleep rather than wakefulness. There is no need for further teaching regarding this statement.

D. This statement also reflects good sleep hygiene practices. Going to bed when feeling naturally tired can enhance the ability to fall asleep quickly. It aligns with the concept of associating the bed with sleepiness and promotes sleep onset. There is no need for further teaching regarding this statement.

A. Handling the skin gently B. Ensure daily bathing C. Clothing that will maintain body warmth D. Using skin moisturizers after bathing E. Fluid intake of no more than about 1000 mL

Correct Answer is ["A","C","D"]

Explanation

A. Older adult skin is typically more fragile and prone to injury and tears due to decreased elasticity and thinning. Handling the skin gently helps prevent trauma, skin tears, and bruising, promoting skin integrity and comfort.

C. Older adults are more susceptible to temperature changes and may have difficulty regulating body temperature. Appropriate clothing that helps maintain warmth without causing overheating is essential. This includes wearing layers that can be easily adjusted and using fabrics that are breathable and comfortable.

D. Older adult skin tends to be drier due to decreased oil production and reduced hydration levels. Applying moisturizers after bathing helps replenish lost moisture, maintain skin hydration, and prevent dryness and cracking. It is important to choose moisturizers that are suitable for older adult skin and free from irritants.

B. Daily bathing may not be necessary or suitable for all older adults. Excessive bathing can strip the skin of natural oils, leading to dryness and irritation. Instead, the nurse should promote bathing frequency based on individual skin needs, such as using mild, moisturizing cleansers and lukewarm water.

E. Adequate hydration is crucial for maintaining skin health and overall well-being in older adults. While fluid needs vary among individuals, restricting fluid intake to such a low level (1000 mL) is generally not

appropriate unless medically indicated. Older adults should be encouraged to maintain adequate hydration to support skin elasticity, circulation, and overall 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

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Explanation

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