A nurse is talking with a client who reports acute lower back pain after moving heavy boxes. Which of the following information should the nurse reinforce? D

Turn the torso at the waist when reaching for objects.

Remain in bed except for toileting during the first 24 hr.

Use ice packs intermittently for 48 hr.

Use 10 lb arm weights to begin strengthening the back muscles.

Answer and Explanation

The Correct Answer is C

A.   The nurse should reinforce that the client should avoid twisting at the waist when lifting or reaching. Instead, they should pivot with their feet and keep their back straight to minimize strain on the lower back.
B.   Prolonged bed rest is generally not recommended for acute lower back pain. While resting is important, clients are usually encouraged to engage in light activity and movement as tolerated to prevent stiffness and promote healing. Staying in bed for extended periods can lead to more problems.
C.   Ice packs can help reduce inflammation and numb the pain in the initial stages of injury. Applying ice intermittently for 15-20 minutes at a time can be beneficial during the first 48 hours after an acute injury.
D.   This option is not advisable for a client experiencing acute lower back pain. Strengthening exercises should be introduced gradually and only after the acute pain has subsided. Initially, the focus should be on gentle stretching and movement rather than adding weights, which could exacerbate the injury.

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Correct Answer is C

Explanation

A. This is a subjective indicator of pain. The pain rating is based on the client’s personal experience and perception of their pain intensity. It reflects the individual’s feelings rather than observable data.
B. This statement is also subjective. Describing pain as a "burning sensation" comes from the client's personal experience and interpretation of their symptoms, which cannot be measured or observed by others.
C. This is an objective indicator of pain. A grimace is an observable behavior that can indicate discomfort or pain. It is something that the nurse can see and assess, making it an objective finding.
D. This is another subjective indicator. While knowing the location of pain is important for diagnosis and treatment, the statement reflects the client’s personal experience of pain and cannot be measured or observed directly.

A. Increased ability to detect temperature B. Burning sensation in feet C. Loss of sensation to pressure D. Hyperreflexia

Correct Answer is B

Explanation

A. Peripheral neuropathy typically results in a decreased ability to detect temperature changes due to nerve damage. Clients often experience reduced sensation or may not feel temperature variations accurately.
B. This is a common symptom of peripheral neuropathy. Many clients report a burning, tingling, or "pins and needles" sensation in their feet. This phenomenon is often associated with nerve damage, especially in conditions like diabetes.
C. Peripheral neuropathy can lead to diminished or altered sensation, including the inability to sense pressure accurately. Clients may not feel pressure on their feet, which increases the risk of injuries and ulcers.
D. Hyperreflexia refers to increased reflex responses, which may occur with upper motor neuron lesions or central nervous system issues, not peripheral nerve damage. Peripheral neuropathy usually results in diminished reflexes or areflexia.

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A nurse is talking with a client who reports acute lower back pain after moving heavy boxes. Which of the following information should the nurse reinforce? D

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data on a client for manifestations of pain. Which of the following findings is an objective indicator of pain?

Correct Answer is C

Explanation

A nurse is collecting data on a client who has peripheral neuropathy. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

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