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:
This statement is not accurate and may confuse the client. In a Patient-Controlled Analgesia (PCA) system, a predetermined dose is delivered when the patient activates the device. The dose is usually controlled to prevent excessive medication administration.
Choice B rationale:
This statement is correct. The essence of PCA is that the patient has control over administering their pain medication within set limits or time intervals. The patient can self-administer doses when needed, ensuring effective pain management.
Choice C rationale:
Allowing the partner to push the PCA button for the patient is not recommended. PCA systems are designed to be controlled by the patient themselves to prevent potential overdosing. Involving someone else in the administration can lead to safety concerns.
Choice D rationale:
PCA systems do not deliver medication into the muscle. They typically deliver medication intravenously (IV) or subcutaneously. This statement is inaccurate and could lead to misconceptions about how the PCA system works.
Correct Answer is D
Explanation
Choice A rationale:
Some older adults may indeed have concerns about taking pain medication, but this is not a primary reason for their hesitance to express pain. The fear of taking medication is not a universal characteristic of older adults.
Choice B rationale:
While older adults may be reluctant to bother nursing staff, this is not the primary reason for their reluctance to express pain. It is a consideration but not the main factor.
Choice C rationale:
The unawareness of discomfort is not a common reason for older adults to avoid expressing pain. Most older adults are aware of their discomfort but may not express it for other reasons.
Choice D rationale:
Older adults may have been culturally trained not to complain about pain or discomfort. In some cultures, stoicism and not burdening others with one's pain are highly valued. This cultural training can lead older adults to underreport their pain.
Choice E rationale:
Believing pain is a natural consequence of aging is a misconception, but it is not the primary reason why older adults may not express their pain. They may believe this, but cultural and societal factors have a more significant impact.
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