An adult male with a right below the knee amputation is complaining of sharp pain in the removed limb.
What is the best response from the nurse?
"What is your pain level on a scale of 0-10?".
"It is not possible to experience pain, the limb and nerves were removed.”.
"You are not experiencing pain.”.
"I understand you are in pain, please rate your pain on a scale of 0-10, and I will get a mirror to assess the area.”. .
The Correct Answer is D
Choice A rationale:
Asking the patient to rate their pain on a scale of 0-10 is a good initial response to assess the severity of pain. However, it should be followed by a more comprehensive assessment, which may include addressing the patient's concern about pain in the removed limb and providing appropriate interventions.
Choice B rationale:
Telling the patient that it is not possible to experience pain because the limb and nerves were removed is inaccurate and insensitive. This response does not address the patient's reported pain and may be perceived as dismissive.
Choice C rationale:
Telling the patient that they are not experiencing pain is both inaccurate and dismissive of the patient's reported pain. This response does not demonstrate empathy or a patient-centered approach to care.
Choice D rationale:
"I understand you are in pain, please rate your pain on a scale of 0-10, and I will get a mirror to assess the area" is the best response. This response acknowledges the patient's pain, uses a pain assessment scale to quantify the pain, and offers a solution to assess the area with a mirror. It demonstrates empathy and a proactive approach to addressing the patient's concern. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Going to bed hungry or overly full can interfere with sleep. When you're too hungry, your body may be uncomfortable and unable to relax, making it difficult to fall asleep. Conversely, going to bed overly full can lead to discomfort, and indigestion, and may result in disrupted sleep. Therefore, it does not help the patient reach REM (Rapid Eye Movement) sleep faster.
Choice B rationale:
Overeating or going to bed hungry does not aid in reaching REM sleep faster. It is essential for individuals to have a balanced diet and avoid excessive hunger or fullness to promote a healthy sleep pattern. REM sleep is a stage of deep sleep that occurs cyclically throughout the night, and it is influenced by various factors, including individual sleep patterns and circadian rhythms.
Choice C rationale:
REM sleep, a stage of deep sleep, is not influenced by going to bed hungry or overly full. Instead, it is primarily regulated by the body's internal clock and sleep-wake cycles. Factors such as hunger or fullness may affect the quality of sleep but do not contribute to reaching REM sleep faster.
Choice D rationale:
False. Going to bed hungry or overly full does not have a direct impact on the patient's ability to reach REM sleep faster. REM sleep is a natural part of the sleep cycle and is influenced by various factors, such as circadian rhythms, sleep disorders, and medications, but not by the state of hunger or fullness.
Correct Answer is B
Explanation
The correct answer is B. Responsibility.
Choice A rationale:
“Fairness.” Fairness involves treating all clients equally and without bias. While fairness is an important aspect of professionalism, it is not specifically demonstrated by evaluating the effectiveness of pain medication.
Choice B rationale:
“Responsibility.” Responsibility refers to the nurse’s duty to provide safe and effective care. By checking the client to evaluate the effectiveness of pain medication, the nurse is fulfilling their responsibility to monitor the client’s response to treatment and ensure their comfort and well-being.
Choice C rationale:
“Confidence.” Confidence involves the nurse’s self-assurance in their skills and knowledge. While confidence is important in nursing practice, it is not the primary component demonstrated in this scenario.
Choice D rationale:
“Advocacy.” Advocacy involves supporting and speaking up for the client’s needs and preferences. Although advocacy is a crucial part of nursing, the act of evaluating pain medication effectiveness is more directly related to the nurse’s responsibility to provide appropriate care.
By demonstrating responsibility, the nurse ensures that the client’s pain management is effective and that any necessary adjustments to the treatment plan are made.
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