A nurse is caring for an adult male client who is alert and oriented x4 on the medical-surgical unit.
In regard to the pain experience, which of the following is correct?
Vital signs can validate pain
Chronic pain is mostly physiological in nature
Secondary data from the wife is pertinent
The client is the best authority in regard to their pain experience
The Correct Answer is D
Choice A rationale:
Vital signs may change with acute pain but do not reliably validate pain, as chronic pain often occurs without significant physiologic alterations in vital signs.
Choice B rationale:
Chronic pain involves both physiological and psychological components, including emotional, cognitive, and behavioral factors, so it is not mostly physiological in nature.
Choice C rationale:
Secondary data from family may provide context but cannot replace the client’s self-report, which is the most accurate measure of pain experience.
Choice D rationale:
The client is the best authority on their pain, as pain is a subjective experience and self-report remains the most reliable indicator for assessment and management.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
A blood pressure of 128/80 mmHg is considered within the normal to slightly elevated range according to current cardiovascular guidelines. Normal blood pressure is generally defined as less than 120/80 mmHg. Lisinopril, an ACE inhibitor, is indicated for hypertension and would typically be administered at this level to maintain therapeutic control. There is no clinical indication of hypotension at this reading, so holding the medication would be inappropriate for this client.
Choice B rationale
A blood pressure of 146/70 mmHg indicates isolated systolic hypertension. The systolic pressure is significantly above the target range of less than 120 mmHg. Administering lisinopril is necessary here to reduce systemic vascular resistance and lower the blood pressure toward a safer therapeutic goal. Holding the medication at this level would allow the hypertension to persist, increasing the risk of long-term vascular damage or acute cardiac events for the client.
Choice C rationale
A blood pressure of 102/58 mmHg is nearing the threshold for hypotension, which is generally defined as a systolic pressure less than 90 mmHg or a diastolic less than 60 mmHg. For a client on antihypertensives like lisinopril, this low reading suggests that further vasodilation could cause symptomatic hypotension or decreased organ perfusion. The nurse should hold the dose and notify the provider to prevent a dangerous drop in blood pressure and syncope.
Choice D rationale
A reading of 110/82 mmHg is considered a normal or pre-hypertensive blood pressure. It does not meet the criteria for hypotension that would warrant holding a scheduled cardiac medication. Lisinopril works by inhibiting the angiotensin-converting enzyme, which prevents the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. At 110/82 mmHg, the client is stable, and the medication is likely working effectively to maintain these desired cardiovascular parameters.
Correct Answer is B
Explanation
Choice A rationale
Spironolactone is a potassium-sparing diuretic typically used to treat hypertension, edema, or heart failure. It works by antagonizing aldosterone receptors in the distal renal tubules, leading to the excretion of sodium and water while retaining potassium. It has no pharmacological mechanism to lower uric acid levels or reduce the inflammatory response associated with gout. Normal serum potassium levels are 3.5 to 5.0 mEq/L, and this medication requires monitoring to prevent hyperkalemia during therapy.
Choice B rationale
Allopurinol is a xanthine oxidase inhibitor used as a maintenance medication to treat gout. It works by reducing the production of uric acid in the body. Gout is caused by hyperuricemia, where serum uric acid levels often exceed 6.8 mg/dL, leading to the deposition of urate crystals in joints. By lowering uric acid levels, allopurinol prevents the formation of these crystals and reduces the frequency of acute gouty attacks. It is essential for long-term management.
Choice C rationale
Alprazolam is a benzodiazepine used primarily for the treatment of anxiety disorders and panic attacks. It works by enhancing the effects of gamma-aminobutyric acid, which is an inhibitory neurotransmitter in the central nervous system. While it provides sedation and muscle relaxation, it does not address the underlying pathophysiology of gout, which is a metabolic and inflammatory condition. It would be inappropriate for treating joint pain or high uric acid levels in a gouty client.
Choice D rationale
Zolpidem is a non-benzodiazepine sedative-hypnotic medication used for the short-term treatment of insomnia. It interacts with the GABA-BZ receptor complex to induce sleep. While a client with gout may have difficulty sleeping due to intense joint pain, zolpidem is not a treatment for gout itself. It does not possess analgesic or anti-inflammatory properties and does not affect uric acid metabolism. The nurse should prioritize medications that directly target the inflammatory process or uric acid production.
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