A nurse is caring for a patient experiencing pain related to a musculoskeletal disorder. Which statement about chronic pain is most accurate?

Chronic pain could cause restlessness, pacing, grimacing, and other facial expressions of pain.

Chronic pain is limited and short in duration.

A patient with chronic pain may have physical signs of tissue injury.

Chronic pain may not manifest in a change of vital signs.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Chronic pain can manifest in various behavioral and physical symptoms, including restlessness, pacing, grimacing, and other facial expressions of pain. These behaviors are often unconscious attempts to cope with or distract from the pain.

They may also reflect the emotional distress that often accompanies chronic pain. Patients may feel frustrated, anxious, or even depressed due to the persistent nature of their pain and its impact on their lives.

It's crucial for nurses to recognize these behavioral signs of pain, as patients may not always readily report their pain verbally. By observing these behaviors, nurses can assess the patient's pain level more accurately and provide appropriate interventions.

Choice B rationale:

Chronic pain is defined as pain that persists for longer than three months, often for much longer. It is not limited and short in duration.

This distinguishes it from acute pain, which is typically associated with an injury or illness and resolves within a few days or weeks.

Choice C rationale:

While some patients with chronic pain may have physical signs of tissue injury, this is not always the case. Chronic pain can also be caused by nerve damage, inflammation, or changes in the central nervous system.

In some cases, the underlying cause of chronic pain may be unknown.

Choice D rationale:

Although chronic pain may not always cause a significant change in vital signs, it can still be a very real and debilitating experience for patients.

Vital signs, such as heart rate, blood pressure, and respiratory rate, are often more sensitive to acute pain.

Nurses should not rely solely on vital signs to assess chronic pain. Instead, they should consider the patient's self-report of pain, behavioral cues, and other factors.

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Correct Answer is A

Explanation

Rationale for Choice A:

Ineffective airway clearance is the most immediate and life-threatening concern in the postoperative period following a radical neck dissection. This procedure involves extensive removal of lymph nodes and tissues in the neck, which can significantly disrupt normal respiratory function and airway patency. Here's a detailed explanation of the factors contributing to this risk:

Altered Respiratory Anatomy: The surgical resection of tissues and lymph nodes can directly impact the structure and function of the airway. This includes potential narrowing of the trachea, vocal cord dysfunction, and impaired laryngeal movement, all of which can hinder effective airflow.

Thick, Copious Secretions: The surgical trauma and manipulation of tissues often lead to increased production of thick, tenacious secretions in the respiratory tract. These secretions can obstruct the airway, making it difficult for the patient to clear them effectively.

Impaired Cough Reflex: The surgical dissection may disrupt the nerves involved in the cough reflex, which is a crucial mechanism for clearing secretions from the airway. This further impedes the patient's ability to maintain a patent airway.

Risk of Aspiration: Accumulation of secretions in the airway elevates the risk of aspiration, which can lead to pneumonia and other serious complications.

Potential for Edema: Postoperative swelling in the neck tissues can further compress the airway, exacerbating the risk of obstruction.

Nursing Interventions for Ineffective Airway Clearance:

Prompt recognition and management of ineffective airway clearance are essential to prevent respiratory compromise and ensure patient safety. Here are key nursing interventions that should be prioritized:

Frequent Assessment: Continuously monitor respiratory rate, effort, breath sounds, oxygen saturation, and level of consciousness for any signs of respiratory distress.

Positioning: Elevate the head of the bed to 30-45 degrees to promote lung expansion and facilitate drainage of secretions. Suctioning: Regularly suction the airway to remove secretions, using aseptic technique and proper suctioning pressure.

Deep Breathing and Coughing Exercises: Encourage and assist the patient with deep breathing and coughing exercises to mobilize secretions.

Humidification: Provide humidified oxygen or use a nebulizer to help thin secretions and make them easier to expectorate.

Chest Physiotherapy: Perform chest physiotherapy techniques, such as percussion and vibration, to loosen secretions and promote their removal.

Monitoring Fluid Balance: Maintain adequate hydration to help thin secretions, while closely monitoring fluid intake and output to prevent fluid overload.

Addressing Other Choices:

While the other choices may also be relevant concerns in the postoperative period, they do not pose the same immediate threat to life as ineffective airway clearance.

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 nurse is caring for a patient experiencing pain related to a musculoskeletal disorder. Which statement about chronic pain is most accurate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient after a radical neck dissection.What should be the nurse’s priority in the immediate postoperative period?

Correct Answer is A

Explanation

Anaphylactic shock is a subgroup of which type of shock?

Correct Answer is D

Explanation

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