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 A
Explanation
The patient with a recent abdominal incision has an abdominal binder applied. The nurse explains that this appliance helps reduce pain by: The correct answer is choice A: supporting surface and internal tissues.
Choice A rationale:
An abdominal binder is primarily used to support surface and internal tissues. It provides gentle compression and support to the abdominal area, which can reduce pain and discomfort. By holding the incision site together and supporting the surrounding tissues, it can minimize movement and strain on the incision, helping to alleviate pain.
Choice B rationale:
While an abdominal binder may indirectly contribute to back support by stabilizing the abdominal area, its primary purpose is to support the surgical site. Enhancing early ambulation is more related to patient mobility and not the primary purpose of the binder.
Choice C rationale:
Abdominal binders do not increase warmth to the incision site. In fact, excessive warmth can lead to sweating and moisture, potentially increasing the risk of infection. The primary purpose is to provide support.
Choice D rationale:
An abdominal binder does not keep sutures and staples in place. The sutures and staples are used to secure the incision, and the binder is placed over them to provide support and compression. However, the binder itself is not responsible for keeping sutures and staples in place. .
Correct Answer is C
Explanation
Choice A rationale:
Increasing pain over several hours is not a typical sign of a fentanyl patch overdose. Fentanyl is a potent opioid, and overdose symptoms often involve respiratory depression, altered mental status, and other serious issues. While it is possible for a patient to experience increased pain if the fentanyl patch is not providing adequate pain relief, this is not a specific sign of overdose.
Choice B rationale:
An itchy red rash on the skin is not a sign of a fentanyl patch overdose but can be associated with skin irritation or allergies to the adhesive in the patch. It's important to differentiate between a skin reaction and an overdose when evaluating patients using fentanyl patches. Overdose symptoms are more severe and life-threatening.
Choice C rationale:
Confusion and the inability to walk normally are characteristic signs of a fentanyl patch overdose. Fentanyl is a potent opioid, and overdose can lead to central nervous system depression, resulting in confusion, altered mental status, and difficulty with coordination and walking. These symptoms are serious and require immediate medical attention.
Choice D rationale:
Headache and nausea are not specific signs of a fentanyl patch overdose. While opioid overdose can cause various symptoms, such as respiratory depression and altered mental status, headache and nausea are not among the primary indicators. However, individual responses to medications can vary, and some patients may experience these symptoms as part of a broader set of overdose signs.
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