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
Explanation
Choice A rationale:
Hypovolemic shock is a life-threatening condition that occurs when the body loses a significant amount of blood or fluids, leading to a decrease in circulating blood volume. This can result in inadequate perfusion of organs and tissues, which can cause damage and even death if not treated promptly.
In this case, the athlete's symptoms and vital signs are consistent with hypovolemic shock. The athlete has been practicing twice a day in the heat, which can lead to significant fluid loss through sweating. The athlete is also dizzy, which is a common symptom of hypovolemia due to decreased blood flow to the brain. The athlete's blood pressure is low (100/2 mm Hg), pulse rate is elevated (100 beats/minute), and respiratory rate is increased (26 breaths/minute), all of which are compensatory mechanisms to try to maintain blood pressure and perfusion in the setting of hypovolemia. The athlete's skin is cool to touch
and pale in color, which is due to decreased blood flow to the skin. The athlete also does not remember the last voiding time, which may indicate decreased urine output, another sign of hypovolemia.
Key points supporting hypovolemic shock:
Significant fluid loss due to exercise in the heat Dizziness
Low blood pressure Elevated pulse rate Increased respiratory rate Cool, pale skin
Decreased urine output Additional details:
Hypovolemic shock can be caused by various factors, including:
Hemorrhage (blood loss) Severe dehydration Burns
Severe vomiting or diarrhea
Treatment for hypovolemic shock typically involves:
Intravenous fluid replacement to restore circulating blood volume Blood transfusion if the shock is due to hemorrhage
Oxygen therapy to support breathing
Medications to support blood pressure and heart function
Correct Answer is C
Explanation
Choice A rationale:
Irreversible shock is the final stage of shock, where the body's compensatory mechanisms have failed, and damage to vital organs is irreversible. This stage is characterized by:
Profound hypotension (systolic blood pressure persistently below 60 mmHg) Severely altered mental status (unresponsiveness or coma)
Widespread organ failure (kidney failure, liver failure, respiratory failure) Lack of response to aggressive fluid resuscitation and vasopressor therapy
The patient in the question does not exhibit all of these signs and symptoms, particularly the profound hypotension and irreversible organ failure. Therefore, irreversible shock is not the most likely stage.
Choice B rationale:
End-organ dysfunction is a stage of shock where inadequate tissue perfusion has begun to cause damage to vital organs. This stage is characterized by:
Hypotension that may respond to fluid resuscitation
Signs of organ dysfunction, such as decreased urine output, altered mental status, or respiratory distress
The patient in the question does have some signs of organ dysfunction, such as confusion and crackles on lung auscultation. However, the hypotension is not as severe as typically seen in end-organ dysfunction shock, and there is no mention of other organ dysfunction like decreased urine output. Therefore, end-organ dysfunction is not the most likely stage.
Choice C rationale:
Early reversible shock is the initial stage of shock, where the body's compensatory mechanisms are still able to maintain blood pressure and organ perfusion. This stage is characterized by:
Mild to moderate hypotension Tachycardia
Cool, clammy skin Narrowed pulse pressure Restlessness or anxiety
The patient in the question presents with all of these signs and symptoms, making early reversible shock the most likely stage.
Choice D rationale:
Preshock is a state of impending shock, where the body's compensatory mechanisms are activated but not yet fully effective. This stage is characterized by:
Normal or slightly low blood pressure Tachycardia
Cool, clammy skin Restlessness or anxiety
The patient in the question has hypotension, which is not consistent with preshock. Therefore, preshock is not the correct stage.
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