A nurse is caring for a client who is recovering from an above-the-knee amputation and reports pain in the limb that was removed. How would the nurse respond?
The pain you are feeling does not actually exist.
This type of pain is common and will eventually go away.
Would you like to learn how to use imagery to minimize your pain?
How would you describe the pain that you are feeling?
The Correct Answer is D
Choice A reason: Stating that phantom limb pain “does not actually exist” dismisses the client’s experience. Phantom pain is a real neurological phenomenon where the brain perceives pain from the absent limb due to nerve endings at the stump sending signals to the cortex.
Choice B reason: While phantom limb pain is common post-amputation, stating it will “eventually go away” oversimplifies management. Pain may persist due to neuroplastic changes in the sensory cortex, requiring interventions like medications or therapy, and this response does not address immediate needs.
Choice C reason: Offering imagery is a valid pain management strategy, as it can modulate pain perception via cognitive distraction. However, it assumes the pain’s nature without assessing its characteristics, which is critical for tailoring interventions like medications or nerve blocks.
Choice D reason: Asking the client to describe phantom limb pain allows the nurse to assess its quality, intensity, and triggers. This informs targeted interventions, as phantom pain results from nerve sensitization and cortical reorganization, requiring a combination of pharmacological (e.g., gabapentin) and non-pharmacological approaches.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Placing the client in a high-Fowler position may improve breathing but does not assess the cause of shortness of breath. Post-femur repair, pulmonary embolism (PE) is a risk due to fat emboli or thromboembolism, requiring objective data like oxygen saturation first.
Choice B reason: New-onset shortness of breath and tachypnea post-femur repair suggest possible pulmonary embolism or fat embolism syndrome. Documenting oxygen saturation provides objective data to assess hypoxia severity, guiding urgent interventions and communication with the healthcare provider for suspected life-threatening conditions.
Choice C reason: Starting oxygen therapy assumes hypoxia without confirmation. While it may be needed, assessing oxygen saturation first ensures the intervention is appropriate. Unwarranted oxygen administration could delay critical diagnostic steps for conditions like pulmonary embolism, which require anticoagulation or other therapies.
Choice D reason: Contacting the provider is important but secondary to assessing oxygen saturation, which provides critical data to report. Without objective findings, the nurse cannot convey the urgency or specifics of the client’s condition, potentially delaying life-saving interventions for suspected embolism.
Correct Answer is D
Explanation
Choice A reason: Stopping antibiotics when symptoms resolve risks incomplete bacterial eradication, leading to recurrent or resistant otitis media. Antibiotics must be taken for the full course to ensure all pathogens (e.g., Streptococcus pneumoniae) are eliminated, preventing chronic infection or complications.
Choice B reason: Sharing antibiotics with siblings is dangerous, as it may lead to incorrect dosing, inappropriate treatment, or antibiotic resistance. Each child requires a specific prescription based on their condition, weight, and bacterial susceptibility, making this an unsafe practice.
Choice C reason: Giving antibiotics with milk may reduce absorption for some drugs (e.g., amoxicillin), as calcium can bind to certain antibiotics, decreasing bioavailability. This statement indicates a misunderstanding, as water is typically recommended to ensure optimal drug absorption.
Choice D reason: Administering the full course of antibiotics ensures complete eradication of bacteria causing otitis media, preventing recurrence or resistance. This reflects proper understanding, as completing the prescribed regimen targets pathogens like Haemophilus influenzae, ensuring effective treatment and reducing complication risks.
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