The nurse takes into consideration the Joint Commission on Accreditation of Healthcare Organizations (CAHO) standards for pain assessment and treatment.
Include:.
Pain is assessed only for patients who complain of pain.
Pain treatment ends at discharge.
All patients have the right to appropriate assessment of pain.
Pain treatment is based on objective data collected by the nurse.
The Correct Answer is C
Choice A rationale:
False. Pain should not be assessed only for patients who complain of pain. Pain assessment should be a routine part of patient care, as not all patients may be able to verbalize their pain or may underreport it. Identifying and addressing pain is crucial for patient well-being.
Choice B rationale:
False. Pain treatment does not necessarily end at discharge. The management of pain may continue beyond the hospital setting, and a plan for pain management post-discharge may be needed. This ensures that patients receive appropriate pain relief and support during their recovery.
Choice C rationale:
True. According to the Joint Commission's standards, all patients have the right to appropriate assessment of pain. This means that every patient, regardless of their condition or the presence of pain complaints, should have their pain assessed and managed as necessary.
Choice D rationale:
False. Pain treatment is not solely based on objective data collected by the nurse. Pain is a subjective experience, and it is essential to consider the patient's self-report of pain, in addition to any objective data, when determining the appropriate treatment. Objective data can help, but it should not be the sole basis for pain management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. "Why do you think your husband needs more medication when he is asleep?"
Choice A rationale:
"Your husband should decide when more medication is needed.” This response is incorrect because it implies that the partner has the authority to decide when the client needs pain medication, which violates the purpose of a PCA pump. A PCA pump is specifically designed for client-controlled pain management, ensuring that the patient, not anyone else, controls when they receive pain medication. Allowing someone else to press the button can lead to overmedication and safety risks.
Choice B rationale:
"Why do you think your husband needs more medication when he is asleep?" This response is correct because it prompts the partner to reflect on their actions and provides an opportunity for the nurse to educate about the proper use of PCA pumps. It addresses the immediate issue without being confrontational and opens the door for further discussion on the importance of client safety and correct PCA use.
Choice C rationale:
"It's a good idea to help make sure your husband can sleep comfortably.” This response is incorrect as it endorses inappropriate and unsafe behavior. It encourages the partner to continue pressing the PCA button, risking the client's safety due to potential overmedication, which can lead to severe complications, such as respiratory depression.
Choice D rationale:
"Next time you think he needs more medication, call me and I'll push the button.” This response is incorrect because it contradicts PCA protocols and removes the control from the client. The nurse is responsible for monitoring the client’s pain and safety, not administering medication upon another person’s request. This approach also increases the risk of dosing errors and undermines the purpose of patient-controlled analgesia.
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. .
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