A nurse is caring for a patient who fell on the ice and has connective tissue damage in the wrist and hand. The patient describes the pain as throbbing. Which type of pain does the nurse document in this patient’s medical record?
Peripherally generated pain
Somatic pain
Visceral pain
Centrally generated pain
The Correct Answer is B
Choice A reason: Peripherally generated pain is a broad term encompassing pain from peripheral nerves, including somatic and visceral pain. It is not specific enough to describe throbbing pain from connective tissue damage in the wrist and hand, which aligns with somatic pain’s characteristics. This choice is too vague for accurate documentation.
Choice B reason: Somatic pain arises from musculoskeletal structures like connective tissue, bones, or joints, often described as throbbing or aching. The patient’s wrist and hand injury from a fall matches this, as damaged ligaments or tendons produce localized, somatic pain. This is the most accurate term for documentation in the medical record.
Choice C reason: Visceral pain originates from internal organs and is typically diffuse, cramping, or burning, not throbbing. Wrist and hand connective tissue damage is musculoskeletal, not organ-related. This type does not fit the injury’s location or description, making it incorrect for the patient’s pain documentation.
Choice D reason: Centrally generated pain results from central nervous system dysfunction, like fibromyalgia or post-stroke pain, and is not localized to an injury site. The patient’s throbbing pain from a wrist injury is peripheral and somatic, not central, making this an incorrect choice for the medical record.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Melatonin, used for sleep regulation, may cause mild drowsiness but is not strongly linked to falls in older adults. Its side effects are minimal, and it does not significantly impair balance or coordination. This medication is unlikely to have caused the fall, making it an incorrect choice.
Choice B reason: Benzodiazepines, used for anxiety or insomnia, increase fall risk in older adults by causing sedation, dizziness, and impaired coordination. These effects, especially at night, can lead to balance issues and falls. Given their known association with falls in the elderly, this is the most likely medication contributing to the incident.
Choice C reason: L-tryptophan, an amino acid supplement for sleep or mood, has minimal side effects and is not associated with significant sedation or balance impairment. It is unlikely to cause falls in older adults, as it does not affect motor function or coordination, making this an incorrect choice.
Choice D reason: Iron supplements treat anemia but do not cause sedation, dizziness, or balance issues linked to falls. Side effects like gastrointestinal upset are unrelated to fall risk. This medication is not a likely contributor to the patient’s fall, making it an incorrect choice compared to benzodiazepines.
Correct Answer is B
Explanation
Choice A reason: Immediate intubation is premature without first reversing opioid-induced respiratory depression with naloxone. Morphine’s rapid onset of lethargy and shallow breathing (7 breaths/min) indicates overdose, reversible by naloxone. Intubation is invasive and reserved for non-responsive cases, risking unnecessary complications when reversal is feasible, delaying targeted treatment in this acute scenario.
Choice B reason: Administering naloxone is the priority for opioid overdose, as evidenced by lethargy and respiratory depression (7 breaths/min) post-morphine. Naloxone, an opioid antagonist, rapidly reverses these life-threatening effects, restoring breathing and consciousness. Prompt administration is critical in older adults, who are more sensitive to opioids, ensuring patient safety and preventing hypoxia or death.
Choice C reason: Observing for opioid tolerance is inappropriate in this acute situation. Lethargy and shallow breathing indicate overdose, not tolerance, requiring immediate naloxone. Monitoring tolerance delays critical intervention, risking prolonged hypoxia, brain damage, or death, especially in an elderly patient with increased opioid sensitivity post-surgery, where respiratory depression is life-threatening.
Choice D reason: Assessing pain level is irrelevant when the patient exhibits opioid overdose symptoms like lethargy and respiratory depression. Pain assessment is secondary to reversing life-threatening respiratory compromise with naloxone. Delaying intervention for pain evaluation risks patient deterioration, as immediate action is needed to restore breathing and stabilize the patient post-morphine administration.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.