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 B
Explanation
Choice A rationale:
This statement is not accurate and may confuse the client. In a Patient-Controlled Analgesia (PCA) system, a predetermined dose is delivered when the patient activates the device. The dose is usually controlled to prevent excessive medication administration.
Choice B rationale:
This statement is correct. The essence of PCA is that the patient has control over administering their pain medication within set limits or time intervals. The patient can self-administer doses when needed, ensuring effective pain management.
Choice C rationale:
Allowing the partner to push the PCA button for the patient is not recommended. PCA systems are designed to be controlled by the patient themselves to prevent potential overdosing. Involving someone else in the administration can lead to safety concerns.
Choice D rationale:
PCA systems do not deliver medication into the muscle. They typically deliver medication intravenously (IV) or subcutaneously. This statement is inaccurate and could lead to misconceptions about how the PCA system works.
Correct Answer is C
Explanation
The correct answer is: C. Decreased energy.
Choice A reason: Hypotension is not typically associated with obstructive sleep apnea (OSA). OSA is more commonly linked with hypertension due to the frequent arousals during sleep that activate the sympathetic nervous system, leading to increased blood pressure.
Choice B reason: Pneumonia is an infection of the lungs and is not a direct consequence of OSA. While OSA can affect the respiratory system, it does not cause pneumonia. However, individuals with OSA may have a higher risk of respiratory infections due to compromised breathing during sleep.
Choice C reason: Decreased energy is a common symptom of OSA. People with OSA experience repeated episodes of partial or complete upper airway obstruction during sleep, leading to disrupted sleep patterns and insufficient rest. This results in daytime sleepiness and fatigue, which are hallmark signs of the condition.
Choice D reason: Thyroid disease, specifically hypothyroidism, can be associated with OSA, but it is not a direct finding of the condition. Hypothyroidism can lead to changes in the soft tissues of the upper airway and contribute to the development of OSA, but it is not a symptom used to diagnose OSA.
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