A nurse is assessing the pain status of a group of clients. Which of the following findings indicates a client is experiencing referred pain?
A client who has peritonitis reports generalized abdominal pain.
A client who has angina reports substernal chest pain.
A client who has pancreatitis reports pain in the left shoulder.
A client who is postoperative reports incisional pain.
The Correct Answer is C
Referred pain is pain that is felt in a location different from its source due to shared nerve pathways or central nervous system processing. A client who has pancreatitis may experience pain in the left shoulder due to irritation of the diaphragm by pancreatic enzymes or inflammation. This pain is referred from the abdominal cavity to the shoulder through the phrenic nerve.
A client who has peritonitis reports generalized abdominal pain that corresponds to the site of inflammation and infection in the peritoneum. A client who has angina reports substernal chest pain that reflects the ischemia and hypoxia of the myocardium. A client who is postoperative reports incisional pain that is caused by tissue damage and inflammation at the surgical site.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
TPN is a form of intravenous nutrition that provides glucose, amino acids, lipids, vitamins, minerals, and electrolytes to clients who cannot eat or absorb nutrients through their gastrointestinal tract. Discontinuing TPN abruptly can cause a sudden drop in blood glucose levels, leading to hypoglycemia .
Hyperglycemia can occur during TPN administration if the glucose infusion rate is too high or if the client has insulin resistance . Diarrhea can occur as a result of infection, bowel ischemia, or intolerance to enteral feeding . Hypertension can occur due to fluid overload, electrolyte imbalance, or vascular complications .
Correct Answer is B,A,C,D
Explanation
The nurse should first check for contraindications to tPA, such as hemorrhagic stroke, recent surgery, bleeding disorder, or uncontrolled hypertension. Then, the nurse should weigh the client to calculate the correct dose of tPA based on body weight. Next, thenurse should administer the tPA within three hours of symptom onset to improve the chances of recovery. Finally, the nurse should transfer the client to the CCU for close monitoring of vital signs, neurological status, and possible complications.
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