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:
It is not advisable to use sedative pills for long periods of time without consulting a primary care provider. Prolonged use of sedatives can lead to dependence and other adverse effects. Therefore, this choice is incorrect.
Choice B rationale:
Using sedative pills for short periods of time without physician approval is not a safe practice. Even nonprescription medications, including over-the-counter sedatives, should be used under the guidance of a healthcare provider. This choice is incorrect.
Choice C rationale:
The best advice for the patient is to use sedative pills for short periods of time, but it is best to check with the primary care provider first. This is the most appropriate choice as it emphasizes short-term use while also promoting communication with a healthcare provider to ensure the medication's safety and effectiveness.
Choice D rationale:
Using sedative pills for long periods of time without primary care provider approval is not recommended. It can lead to potential risks and side effects associated with prolonged sedative use. Therefore, this choice is incorrect.
Correct Answer is C
Explanation
Choice A rationale:
An elevated blood pressure is not a reliable indicator of a decrease in pain following the administration of an opioid narcotic. Blood pressure can be influenced by various factors, and it may not directly correlate with the relief of pain.
Choice B rationale:
The client being asleep is not a direct indicator of decreased pain following opioid administration. While opioids may cause drowsiness as a side effect, the absence of pain cannot be confirmed solely based on the patient's sleep state.
Choice C rationale:
An increased respiratory rate can be a reliable indicator of decreased pain following the administration of an opioid narcotic. Opioids often cause respiratory depression, so an increased respiratory rate may suggest that the patient's pain is adequately managed, as they are not experiencing excessive respiratory depression.
Choice D rationale:
Diaphoresis (excessive sweating) is not a direct indicator of decreased pain following opioid administration. Diaphoresis can be caused by various factors, including anxiety, and may not specifically reflect pain relief. .
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