In a post-surgical unit, the nurse cares for many patients experiencing pain. Which situation is likely to lower a patient’s pain threshold?
A patient who is awaiting biopsy results.
A patient who is anxious.
A patient who is having difficulty sleeping in the hospital setting.
It is the same for all patients who have had surgery.
The Correct Answer is B
Choice A rationale:
Awaiting biopsy results can certainly cause anxiety and stress, but it doesn't directly impact the physiological mechanisms that modulate pain perception.
While a patient awaiting biopsy results may be more attentive to their bodily sensations, including pain, the anxiety itself is not the primary driver of a lowered pain threshold.
It's important to address the patient's concerns and provide emotional support, but this alone may not be sufficient to manage pain effectively if anxiety is not the primary factor.
Choice B rationale:
Anxiety activates the sympathetic nervous system, which triggers the "fight-or-flight" response. This cascade of physiological changes includes:
Increased heart rate and blood pressure Muscle tension
Dilated pupils
Heightened awareness of bodily sensations
These physiological changes can amplify pain signals and lower the pain threshold, meaning that a person who is anxious may perceive pain more intensely than someone who is calm and relaxed.
This is because anxiety can reduce the effectiveness of the body's natural pain-inhibiting mechanisms, such as the release of endorphins and serotonin.
Choice C rationale:
Difficulty sleeping can also contribute to pain, but its effect on pain threshold is less direct than that of anxiety. Sleep deprivation can lead to:
Increased irritability Decreased pain tolerance Impaired cognitive function
These factors can make it more difficult to cope with pain, but they don't directly lower the threshold at which pain signals are perceived.
Choice D rationale:
Pain threshold varies among individuals due to a variety of factors, including: Genetics
Past experiences with pain Psychological factors Cultural beliefs
Coping mechanisms
It is incorrect to assume that all patients who have had surgery will have the same pain threshold.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale for Choice A: Obtain vital signs
While obtaining vital signs is important in assessing a patient's overall condition, it is not the first priority in a suspected transfusion reaction.
Vital signs can provide valuable information about the severity of the reaction, but they should not delay the immediate action of stopping the transfusion.
Delaying the cessation of the transfusion could allow for further infusion of incompatible blood or allergens, potentially worsening the reaction and leading to more serious complications.
Rationale for Choice B: Notify the registered nurse
Involving other healthcare professionals is crucial in managing transfusion reactions, but it should not precede stopping the transfusion.
The nurse should prioritize stopping the transfusion to prevent further exposure to potential triggers and then promptly notify the registered nurse for further assessment and interventions.
Timely communication with the registered nurse is essential for coordinating care and ensuring appropriate treatment measures are implemented.
Rationale for Choice C: Administer diphenhydramine
Diphenhydramine, an antihistamine, can be used to treat allergic reactions, but it should not be administered as the first response in this scenario.
The priority is to halt the infusion of the blood product that is potentially causing the reaction.
Administering diphenhydramine before stopping the transfusion could mask the symptoms of the reaction, making it more difficult to assess its severity and progression.
Rationale for Choice D: Stop the transfusion
This is the correct and most immediate action to take when a patient develops itching and hives during a blood transfusion.
These symptoms are indicative of a possible allergic or transfusion reaction, and stopping the transfusion is essential to prevent further complications.
It's critical to act quickly to minimize the amount of incompatible blood or allergens that enter the patient's circulation.
By stopping the transfusion, the nurse can potentially prevent the reaction from worsening and safeguard the patient's well- being.
Correct Answer is ["50"]
Explanation
Here are the steps to calculate the gtt/min for the manual IV infusion:
Step 1: Convert the infusion time from hours to minutes. 8 hours x 60 minutes/hour = 480 minutes
Step 2: Divide the total volume of fluid (in mL) by the infusion time in minutes to get the mL/min rate. 400 mL ÷ 480 minutes = 0.8333 mL/min
Step 3: Multiply the mL/min rate by the drop factor (gtt/mL) to get the gtt/min rate. 0.8333 mL/min x 60 gtt/mL = 50 gtt/min
Therefore, the nurse should set the manual IV infusion to deliver 50 gtt/min.
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