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 D
Explanation
Choice A rationale:
Post-herpetic neuralgia. Post-herpetic neuralgia is a neuropathic pain that occurs as a complication of shingles (herpes zoster) and is characterized by severe, burning, or shooting pain in the affected area. It is not an example of nociceptive pain.
Choice B rationale:
Diabetic neuropathy. Diabetic neuropathy is another example of neuropathic pain and is caused by damage to the nerves due to diabetes. It typically presents as aching, burning, or tingling sensations and is not considered nociceptive pain.
Choice C rationale:
Phantom limb pain. Phantom limb pain is also a neuropathic pain that occurs after the amputation of a limb. Patients perceive pain or discomfort in the missing limb. It is not classified as nociceptive pain.
Choice D rationale:
Strained muscle. Strained muscle pain is a classic example of nociceptive pain. Nociceptive pain arises from the activation of pain receptors (nociceptors) due to tissue damage or inflammation. In the case of a strained muscle, the pain results from physical injury or overuse of the muscle, making it a nociceptive pain. Nociceptive pain can be further categorized into somatic and visceral pain. Somatic pain, as in the case of a strained muscle, arises from musculoskeletal structures, and it is typically well-localized, sharp, and aching. Understanding the nature of pain is essential for effective pain management and treatment selection. .
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.
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