In a post-surgical unit, the nurse cares for many patients experiencing pain. Which situation is likely to lower a patient’s pain threshold?
A patient who is awaiting biopsy results.
A patient who is anxious.
A patient who is having difficulty sleeping in the hospital setting.
It is the same for all patients who have had surgery.
The Correct Answer is B
Choice A rationale:
Awaiting biopsy results can certainly cause anxiety and stress, but it doesn't directly impact the physiological mechanisms that modulate pain perception.
While a patient awaiting biopsy results may be more attentive to their bodily sensations, including pain, the anxiety itself is not the primary driver of a lowered pain threshold.
It's important to address the patient's concerns and provide emotional support, but this alone may not be sufficient to manage pain effectively if anxiety is not the primary factor.
Choice B rationale:
Anxiety activates the sympathetic nervous system, which triggers the "fight-or-flight" response. This cascade of physiological changes includes:
Increased heart rate and blood pressure Muscle tension
Dilated pupils
Heightened awareness of bodily sensations
These physiological changes can amplify pain signals and lower the pain threshold, meaning that a person who is anxious may perceive pain more intensely than someone who is calm and relaxed.
This is because anxiety can reduce the effectiveness of the body's natural pain-inhibiting mechanisms, such as the release of endorphins and serotonin.
Choice C rationale:
Difficulty sleeping can also contribute to pain, but its effect on pain threshold is less direct than that of anxiety. Sleep deprivation can lead to:
Increased irritability Decreased pain tolerance Impaired cognitive function
These factors can make it more difficult to cope with pain, but they don't directly lower the threshold at which pain signals are perceived.
Choice D rationale:
Pain threshold varies among individuals due to a variety of factors, including: Genetics
Past experiences with pain Psychological factors Cultural beliefs
Coping mechanisms
It is incorrect to assume that all patients who have had surgery will have the same pain threshold.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Distended neck veins are not a reliable indicator of dehydration in adults. They can be caused by other factors, such as heart failure or fluid overload.
In cases of dehydration, the veins in the neck may actually be less visible due to decreased blood volume.
It's important to assess for other signs and symptoms of dehydration, such as urine output, skin turgor, and vital signs, to make an accurate diagnosis.
Choice B rationale:
A bounding pulse can be a sign of dehydration, but it can also be caused by other factors, such as anxiety, exercise, or fever. It's important to assess the pulse rate and rhythm in conjunction with other signs and symptoms to determine the cause.
A normal pulse rate is 60-100 beats per minute in adults. A bounding pulse is typically a strong, forceful pulse that can be easily felt.
Choice C rationale:
A blood pressure of 146/94 mm Hg is considered elevated, but it is not necessarily a sign of dehydration. Blood pressure can be elevated due to other factors, such as stress, pain, or underlying medical conditions. It's important to assess blood pressure in conjunction with other signs and symptoms to determine the cause. Choice D rationale:
Urine specific gravity is a measure of the concentration of solutes in the urine. A higher urine specific gravity indicates more concentrated urine, which is a sign of dehydration.
A normal urine specific gravity is 1.005-1.030. A urine specific gravity of 1.034 is considered high and is a strong indicator of dehydration.
Correct Answer is D
Explanation
The correct answer is choice d. Auscultate lung fields.
Choice A rationale:
Cupping hands and tapping on the patient’s chest is part of the chest percussion technique, which helps to loosen mucus. However, it is not the first step. Before performing any physical intervention, the nurse must assess the patient’s current respiratory status.
Choice B rationale:
Positioning the patient so that the lung area to be drained is above the trachea is part of postural drainage. This step is crucial but should be done after assessing the patient’s lung fields to determine the areas that need drainage.
Choice C rationale:
Providing mouth care is important for overall hygiene and to prevent infection, especially in patients with respiratory conditions. However, it is not directly related to the immediate assessment and intervention for chest physiotherapy.
Choice D rationale:
Auscultating lung fields is the first step because it allows the nurse to assess the patient’s respiratory status and identify areas with abnormal breath sounds, which will guide the subsequent interventions like chest percussion, vibration, and postural drainage. This assessment ensures that the interventions are targeted and effective.
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