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 D
Explanation
Choice A rationale:
Magnesium is not typically considered a natural supplement that enhances sleep. While magnesium is an essential mineral for overall health, it is not commonly used as a sleep aid.
Choice B rationale:
Calcium is also not commonly used as a natural supplement to enhance sleep. While calcium is important for bone health and various physiological processes, it is not primarily associated with improving sleep.
Choice C rationale:
Oil of lavender is known for its calming and soothing properties, and it can have a relaxing effect. However, it is not as commonly used or as effective as melatonin for improving sleep. Lavender oil is more often used for its aromatherapy benefits.
Correct Answer is B
Explanation
Choice A rationale:
A patient with a decreased level of consciousness from a stroke may not be able to provide feedback or recognize discomfort or pain, which can increase the risk of burn injury when using a heating pad. This choice increases the risk rather than reducing it.
Choice B rationale:
A patient with neuritis secondary to diabetes has a decreased sensitivity in the affected area due to nerve damage. While this can be a challenging condition, it reduces the patient's ability to perceive heat and pain, making them less likely to realize if the heating pad becomes too hot. As a result, this patient has the least risk for burn injury when using the Aquathermia K pad.
Choice C rationale:
A severely sprained ankle is not related to the risk of burn injury from a heating pad. This choice is not relevant to the assessment of burn injury risk with the Aquathermia K pad.
Choice D rationale:
Impaired peripheral circulation can increase the risk of burn injury from a heating pad. Patients with compromised circulation have a reduced ability to dissipate heat, which can lead to localized overheating and potential burn injury. This choice increases the risk of injury. .
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