A 79-year-old patient reports a pain level of 3 out of 10 and states, “Don’t worry, this is just part of getting old.” What is the best response?

“Okay then; let me know if you need anything.”

“That is not bad.

“I understand you have had the pain for a while. Let’s investigate this further.”

you know what might be causing the pain?”

t me know if your pain becomes greater than 4 out of 10; then we can treat it.”

Answer and Explanation

The Correct Answer is C

Choice A rationale:

This response is dismissive of the patient's pain and does not offer any assistance. It also does not acknowledge the patient's concerns about their pain being a normal part of aging.

It's important to validate the patient's experience and offer support, even if the pain level is not severe.

This response could lead to the patient feeling unheard and unsupported, and it could potentially delay necessary treatment.

Choice B rationale:

This response suggests that the patient's pain is not significant enough to warrant treatment unless it worsens. This is not appropriate, as pain is subjective and should be treated based on the patient's individual experience.

Additionally, this response reinforces the patient's belief that pain is a normal part of aging, which may prevent them from seeking treatment in the future.

Choice C rationale:

This response is the best option because it acknowledges the patient's pain, expresses concern, and suggests further investigation.

It is important to rule out any underlying medical conditions that may be causing the pain.

This response also demonstrates to the patient that the nurse is taking their pain seriously and is committed to helping them manage it.

Choice D rationale:

This response acknowledges that pain can be a part of aging, but it also suggests that there may be a specific cause for the patient's pain.

This could lead to the patient feeling anxious or worried about their health.

It is important to investigate the cause of the pain before making any assumptions.

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Correct Answer is C

Explanation

Choice A rationale:

Avoiding crossing legs at the knees is a correct practice for people with PVD. It helps to prevent constriction of blood flow in the legs. When legs are crossed, pressure is applied to the veins in the lower leg, which can impede blood flow. This can lead to several problems, including:

Increased risk of blood clots Worsening of swelling in the legs Increased pain and discomfort Potential skin damage

Reinforcing this practice with the client is important.

Choice B rationale:

Not going barefoot is also a correct practice for people with PVD. It helps to protect the feet from injuries and infections. People with PVD may have reduced sensation in their feet, making them more susceptible to injuries they may not notice. Additionally, PVD can impair wound healing, so even minor injuries can become serious problems.

Reinforcing this practice with the client is important.

Choice C rationale:

Using a thermometer to check bath water temperature is not directly relevant to PVD management. While it's generally a good safety practice to avoid excessively hot water, which can burn the skin, it's not specifically related to the blood flow issues associated with PVD.

This statement indicates a need for further teaching to focus on PVD-specific self-care measures.

Choice D rationale:

Wearing stockings with elastic tops is generally recommended for people with PVD. These stockings, often referred to as compression stockings, help to improve blood flow in the legs by applying gentle pressure. This can help to reduce swelling, pain, and the risk of blood clots.

Reinforcing this practice with the client is important.

A. Hypovolemic B. Obstructive C. Cardiogenic D. Distributive

Correct Answer is D

Explanation

Choice A rationale:

Hypovolemic shock is a type of shock that occurs when there is a significant loss of blood or fluid volume, leading to decreased cardiac output and tissue perfusion. This can be caused by severe bleeding, dehydration, burns, or other conditions that result in fluid loss. While anaphylaxis can involve some fluid shifts, it is not primarily characterized by a loss of blood or fluid volume.

Key features of hypovolemic shock that distinguish it from anaphylactic shock include:

Prominent signs of dehydration: Dry skin and mucous membranes, decreased urine output, sunken eyes, and poor skin turgor.

Hemodynamic changes: Tachycardia, narrow pulse pressure, and cold extremities due to vasoconstriction to maintain blood pressure.

Laboratory findings: Elevated hematocrit and blood urea nitrogen (BUN) levels, indicating hemoconcentration and decreased kidney perfusion.

Choice B rationale:

Obstructive shock is a type of shock that occurs when there is an obstruction to blood flow, preventing adequate circulation to the body's tissues. This can be caused by conditions such as pulmonary embolism, cardiac tamponade, or tension pneumothorax. Anaphylaxis does not involve a physical obstruction to blood flow.

Key features of obstructive shock that distinguish it from anaphylactic shock include:

Evidence of the underlying obstruction: Jugular venous distension (cardiac tamponade), muffled heart sounds (cardiac tamponade), or respiratory distress (pulmonary embolism or tension pneumothorax).

Distinctive hemodynamic changes: Equalization of diastolic pressures between the right and left ventricles (cardiac tamponade).

Specific imaging findings: Enlarged cardiac silhouette on chest X-ray (pericardial effusion), filling defects in the pulmonary arteries on CT angiography (pulmonary embolism), or hyperexpanded lung fields with a deviated trachea on chest X-ray (tension pneumothorax).

Choice C rationale:

Cardiogenic shock is a type of shock that occurs when the heart is unable to pump enough blood to meet the body's needs. This can be caused by conditions such as heart attack, heart failure, or cardiomyopathy. Anaphylaxis does not primarily involve a failure of the heart's pumping function.

Key features of cardiogenic shock that distinguish it from anaphylactic shock include:

Evidence of heart failure: Pulmonary edema, elevated jugular venous pressure, and a third heart sound (S3 gallop).

Electrocardiogram (ECG) changes: ST-segment elevation or depression, Q waves, or other signs of myocardial ischemia or infarction.

Elevated cardiac enzymes: Troponin and creatine kinase-MB (CK-MB) levels, indicating heart muscle damage.

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A 79-year-old patient reports a pain level of 3 out of 10 and states, “Don’t worry, this is just part of getting old.” What is the best response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). Which of the following statements by the client indicates a need for further teaching?

Correct Answer is C

Explanation

Anaphylactic shock is a subgroup of which type of shock?

Correct Answer is D

Explanation

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