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 C
Explanation
Choice A rationale:
Keeping bright lights on in the room is not conducive to relaxation. Bright lights can be stimulating and may increase stress, which is counterproductive when trying to manage pain through relaxation techniques.
Choice B rationale:
Using relaxation techniques as a way to wake up in the morning is not the intended purpose of these techniques. Relaxation techniques are typically used to reduce stress, anxiety, and pain, especially when one is trying to rest or sleep.
Choice C rationale:
Tensing and relaxing individual muscle groups, starting with the toes and feet, is a common method for progressive muscle relaxation. This technique can help reduce muscle tension and promote overall relaxation. It is an effective approach to pain management.
Choice D rationale:
Trying to tense and relax all of the muscles of the body at the same time may be difficult for most individuals and is not a commonly recommended relaxation technique. It can be challenging to achieve the level of focus and control required for this method, and it may not be as effective as focusing on individual muscle groups.
Correct Answer is D
Explanation
Choice A rationale:
The CPAP device should not fit loosely on the face. It should fit snugly to create a proper seal and maintain positive airway pressure. A loose-fitting CPAP mask may not effectively treat obstructive sleep apnea (OSA).
Choice B rationale:
The CPAP device typically delivers consistent pressure throughout both inhalation and exhalation. It does not deliver less pressure during exhalation. The purpose of CPAP is to maintain a constant pressure to keep the airway open during both phases of the respiratory cycle.
Choice C rationale:
The CPAP device does not require an invasive ventilation tube. It uses a mask that covers the nose or both the nose and mouth to deliver positive airway pressure. It is non-invasive and is designed to keep the airway open by delivering pressurized air.
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