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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale:

It is not necessary to remind a patient to avoid turning from side to side after femoral artery catheterization. Restricting movement in this way could actually increase the risk of complications such as deep vein thrombosis (DVT).

Early ambulation is generally encouraged to promote circulation and prevent blood clots.

Patients are typically allowed to turn and reposition themselves as needed for comfort, unless there are specific contraindications.

Choice B rationale:

Keeping the patient in a high-Fowler's position for 6 hours is not a standard recommendation following femoral artery catheterization.

The patient's position should be based on their individual needs and comfort level.

In some cases, a slight elevation of the head of the bed may be helpful to promote venous return, but prolonged high-Fowler's positioning is not necessary.

Choice C rationale:

Passive range-of-motion exercises are not typically performed on the affected extremity immediately following femoral artery catheterization.

This is because there is a risk of dislodging the catheter or causing bleeding at the puncture site.

Once the catheter has been removed and the puncture site has healed, gentle range-of-motion exercises may be recommended to help maintain joint mobility.

Choice D rationale:

Checking pedal pulses every 15 minutes is essential to assess for adequate circulation to the lower extremities following femoral artery catheterization.

This is because there is a risk of complications such as thrombosis or embolism, which can compromise blood flow to the legs and feet.

If the pedal pulses are weak or absent, it could indicate a serious problem that requires immediate intervention.

A. Request NPO status for the client. B. Elevate the head of the bed to high Fowler’s. C. Measure the client’s temperature. D. Check the client’s respiratory rate and lung sounds.

Correct Answer is D

Explanation

NPO status (nothing by mouth) is not a relevant intervention in this situation. It would be indicated for a patient with gastrointestinal issues or prior to a procedure, but it does not address the potential consequences of rapid fluid administration.

Restricting oral intake would not reverse or mitigate the effects of fluid overload that may have already occurred.

It's important to prioritize assessment of the patient's respiratory status, as fluid overload can lead to pulmonary edema, a serious complication.

Rationale for Choice B:

Elevating the head of the bed to high Fowler's position can be helpful in easing breathing for patients with respiratory distress, but it's not the most immediate priority in this case.

Assessing the patient's respiratory status directly through respiratory rate and lung sounds will provide more comprehensive information about potential fluid overload and guide further interventions.

Rationale for Choice C:

Measuring the client's temperature is not directly relevant to the concern of rapid fluid administration.

While fever could be a sign of infection, which might warrant fluid administration, it's not the primary concern in this scenario.

The priority is to assess for potential fluid overload, which could manifest as respiratory distress. Rationale for Choice D:

Checking the client's respiratory rate and lung sounds is the most appropriate action for the nurse to take in this situation.

Rapid infusion of 900 mL of fluid within a short period could lead to fluid overload, which can manifest as: Increased respiratory rate

Crackles in the lungs Shortness of breath Hypoxia

Early identification of these signs is crucial for prompt intervention and prevention of serious complications.

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In a post-surgical unit, the nurse cares for many patients experiencing pain. Which situation is likely to lower a patient’s pain threshold?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient immediately following a cardiac catheterization with a femoral artery approach. Which action should the nurse take?

Correct Answer is D

Explanation

During a shift change report, a nurse notices that a patient’s IV bag of 0.9% sodium chloride has 900 mL of fluid remaining.The nurse checks again 30 minutes later and finds that the IV bag is empty. What should the nurse do in this situation?

Correct Answer is D

Explanation

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