An adult male with a right below the knee amputation is complaining of sharp pain in the removed limb.
What is the best response from the nurse?
"What is your pain level on a scale of 0-10?".
"It is not possible to experience pain, the limb and nerves were removed.”.
"You are not experiencing pain.”.
"I understand you are in pain, please rate your pain on a scale of 0-10, and I will get a mirror to assess the area.”. .
The Correct Answer is D
Choice A rationale:
Asking the patient to rate their pain on a scale of 0-10 is a good initial response to assess the severity of pain. However, it should be followed by a more comprehensive assessment, which may include addressing the patient's concern about pain in the removed limb and providing appropriate interventions.
Choice B rationale:
Telling the patient that it is not possible to experience pain because the limb and nerves were removed is inaccurate and insensitive. This response does not address the patient's reported pain and may be perceived as dismissive.
Choice C rationale:
Telling the patient that they are not experiencing pain is both inaccurate and dismissive of the patient's reported pain. This response does not demonstrate empathy or a patient-centered approach to care.
Choice D rationale:
"I understand you are in pain, please rate your pain on a scale of 0-10, and I will get a mirror to assess the area" is the best response. This response acknowledges the patient's pain, uses a pain assessment scale to quantify the pain, and offers a solution to assess the area with a mirror. It demonstrates empathy and a proactive approach to addressing the patient's concern. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Constipation is not a common adverse effect of pain medication administered by the epidural route. Pain medication primarily affects the central nervous system and does not typically impact the gastrointestinal system in a way that would lead to constipation.
Choice B rationale:
Hypoventilation is the correct answer. When opioids or other potent pain medications are administered by the epidural route, they can depress the respiratory center in the brain, leading to hypoventilation (slow or inadequate breathing). This is a critical concern and the most important adverse effect to monitor because it can lead to respiratory compromise or even respiratory arrest.
Choice C rationale:
Nausea can be a side effect of some pain medications, but it is not the most important adverse effect to monitor in a patient receiving epidural pain medication. Nausea can often be managed with antiemetic medications.
Choice D rationale:
Headache is not a common adverse effect of epidural pain medication. The administration of pain medication into the epidural space is localized to the spinal area and does not typically lead to headaches.
Correct Answer is ["A","B","D","E"]
Explanation
Choice A rationale:
Perception is one of the phases of nociceptive pain. It involves the awareness of pain, where the brain recognizes and interprets the pain signals. During this phase, the individual becomes conscious of the painful sensation.
Choice B rationale:
Transmission is another phase of nociceptive pain. It involves the propagation of pain signals from the site of injury or damage to the central nervous system. Nerve fibers carry the pain signals to the spinal cord and brain for processing.
Choice D rationale:
Modulation is also a phase of nociceptive pain. It refers to the body's ability to modify or regulate the pain signals. This can involve the release of endorphins or other natural pain-relieving substances that help dampen the pain perception.
Choice E rationale:
Transduction is the last phase of nociceptive pain. It is the process where the noxious stimulus (injury or damage) is converted into electrical nerve signals that the body can understand. This conversion allows the pain signal to travel through the nervous system.
Choice C rationale:
Translation is not typically considered one of the phases of nociceptive pain. While translation may refer to the process of converting one form of information to another, it is not a recognized phase in the context of pain perception.
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