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.”
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Choice A rationale:
Intravenous theophylline (aminophylline) is a bronchodilator that can be life-saving in cases of anaphylactic shock with bronchospasm. It works by relaxing the smooth muscles in the airways, allowing for increased airflow.
Anaphylactic shock can cause severe bronchospasm, which can lead to respiratory failure and death. Theophylline can help to reverse bronchospasm and improve oxygenation.
The dosage of theophylline should be individualized based on the patient's weight and severity of bronchospasm. It is important to monitor the patient's heart rate and blood pressure while administering theophylline, as it can cause tachycardia and arrhythmias.
Choice B rationale:
Culturing the site of the bee sting and administering antibiotics is not appropriate in the acute management of anaphylactic shock. Anaphylaxis is an allergic reaction, not an infection. Antibiotics will not address the underlying cause of the reaction.
Antibiotics may be necessary if the patient develops a secondary infection at the site of the bee sting. However, this is not a priority in the acute setting.
Choice C rationale:
Providing sips of water to moisten the mouth and throat is not a priority in the acute management of anaphylactic shock. The patient's primary concern is likely to be difficulty breathing.
If the patient is able to drink, it is important to ensure that they are able to do so safely without compromising their airway. However, this is not a life-saving intervention.
Choice D rationale:
Diphenhydramine (Benadryl) is an antihistamine that can help to block the effects of histamine, one of the chemicals released during an allergic reaction. This can help to reduce symptoms such as swelling, itching, and hives.
Diphenhydramine can also help to prevent further release of histamine, which can help to stop the progression of the allergic reaction.
Diphenhydramine is available over-the-counter, but it is important to consult a healthcare professional before administering it to a patient in anaphylactic shock.
Choice E rationale:
Surgical management of the airway may be necessary if the patient's airway becomes compromised due to swelling. This could include intubation or a tracheostomy.
It is important to be prepared for surgical airway management in case it is needed. Early preparation can help to prevent delays in treatment and improve the patient's chances of survival.
Correct Answer is B
Explanation
Choice B rationale:
Phlebitis is the inflammation of a vein, often caused by an IV catheter. It's characterized by redness, swelling, warmth, and pain along the vein.
Promptly discontinuing the IV infusion is crucial to prevent further irritation and potential complications such as: Thrombophlebitis (inflammation with clot formation)
Infection
Infiltration (leakage of fluids into surrounding tissues) Extravasation (leakage of vesicant or damaging medications)
Continuing the infusion could exacerbate the inflammation and increase the risk of these complications.
Choice A rationale:
Elevation of the extremity can help reduce swelling, but it does not address the underlying inflammation. It's often used as an adjunct measure after discontinuing the IV.
Choice C rationale:
Warm, moist compresses can provide some comfort and potentially promote blood flow, but they are not recommended as a first-line treatment for phlebitis. They may even worsen inflammation in some cases.
Choice D rationale:
Inserting an IV catheter in the opposite extremity is necessary if the patient still requires IV therapy, but it should not be done before addressing the phlebitis in the current site. This could lead to multiple sites of inflammation and increased risk of complications.
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