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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. pH 7.25, PaCO2 61, HCO3 26
pH is decreased (acidosis).
PaCO2 is elevated (61 mmHg), indicating respiratory acidosis (increased CO2 retention). HCO3 is slightly elevated (26 mEq/L), compensating for the respiratory acidosis.
A. pH 7.45, PaCO2 35, HCO3 22
pH is within normal range (7.35-7.45).
PaCO2 is slightly lower than normal (35 mmHg), indicating mild respiratory alkalosis. HCO3 (bicarbonate) is within normal range (22 mEq/L).
C. pH 7.23, PaCO2 27, HCO3 25
pH is decreased (acidosis).
PaCO2 is lower than normal (27 mmHg), indicating respiratory alkalosis (which is unlikely in the context of morphine overdose with hypoventilation).
HCO3 is within normal range (25 mEq/L).
D. pH 7.54, PaCO2 59, HCO3 26
pH is increased (alkalosis).
PaCO2 is elevated (59 mmHg), indicating respiratory acidosis (consistent with hypoventilation). HCO3 is slightly elevated (26 mEq/L), compensating for the respiratory acidosis.
Correct Answer is A
Explanation
A. Restlessness and agitation in nonverbal clients can often be exacerbated by environmental factors such as noise, bright lights, or unfamiliar surroundings. By reducing environmental stimuli, such as dimming lights, minimizing noise, and providing a calm atmosphere, the nurse can help alleviate agitation and promote a more comfortable environment for the client.
B. Suctioning the oropharynx is not typically the first action unless there is a clear indication that airway obstruction or secretion management is contributing to the client's agitation. It is important to first assess whether there are signs of respiratory distress or airway compromise before performing suctioning.
C. Assessing pulse oximetry is important for monitoring oxygen saturation levels, especially if there are concerns about respiratory distress or inadequate oxygenation. However, it is not typically the first action when a client is restless and agitated unless there are specific indications or signs suggesting respiratory compromise.
D. Administering oxygen may be necessary if there are signs of hypoxia or respiratory distress contributing to the client's agitation. However, without assessing the client's oxygenation status first, administering oxygen as the initial action may not address the underlying cause of agitation.
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