The nurse is caring for a client who has kidney disease. The client has urinated 250 mL over the past 24 hours. The nurse describes this urine output as:

polyuria.

retention.

oliguria.

anuria.

Answer and Explanation

The Correct Answer is C

A. Polyuria: Polyuria refers to abnormally large volume of urine output, typically exceeding 2.5 to 3 liters per day in adults. It is often associated with conditions such as diabetes mellitus, diabetes insipidus, or certain medications that increase urine production. Urinating 250 mL over 24 hours does not meet the criteria for polyuria.

B. Retention: Urinary retention refers to the inability to completely empty the bladder, leading to accumulation of urine. It is characterized by difficulty initiating urination or incomplete bladder emptying. Urinating 250 mL over 24 hours does not indicate urinary retention.

C. Oliguria: Oliguria is defined as diminished urine output, typically less than 400 mL per day in adults. It is a common sign of kidney dysfunction or acute kidney injury. Urinating 250 mL over 24 hours falls within the range of oliguria, indicating decreased urine production compared to normal.

D. Anuria: Anuria is the absence of urine production or excretion, typically defined as urine output less than 100 mL per day. It is often indicative of severe kidney dysfunction, renal failure, or obstruction of the urinary tract. While the client's urine output of 250 mL over 24 hours is low, it does not meet the criteria for anuria.

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Correct Answer is ["A","C","D"]

Explanation

A. Chronic:

Chronic pain is characterized by pain that persists beyond the expected time for tissue healing, typically lasting for more than 3 to 6 months.

In this scenario, the client's pain has been present for 1 year, indicating a prolonged duration consistent with chronic pain.

Documenting the pain as chronic provides important information about the nature and duration of the client's pain experience.

C. Intractable:

Intractable pain refers to pain that is difficult to manage or control despite various treatment modalities.

The client's report of intense, sharp pain persisting at a high level (rated 9 out of 10) despite opioid analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), and acupuncture suggests that the pain is intractable.

Documenting the pain as intractable highlights the challenges associated with managing the client's pain and the need for additional interventions or referral to specialized pain management services.

D. Neuropathic:

Neuropathic pain arises from damage or dysfunction of the nervous system and is often described as sharp, shooting, burning, or like an electric shock.

The client's description of their leg pain as "an intense sharp quality 'like an electric shock'" is consistent with neuropathic pain.

Documenting the pain as neuropathic helps identify the underlying pathophysiology of the pain and guides appropriate treatment strategies targeting neuropathic pain mechanisms.

B. Visceral:

Visceral pain originates from internal organs and is typically described as deep, dull, or cramping.

While the pain in this scenario is associated with spinal nerve injury, which can involve visceral pain pathways, the client's description of the pain as sharp and electric shock-like is more indicative of neuropathic pain rather than visceral pain.

Therefore, visceral pain may not be an appropriate descriptor for the client's pain experience in this case.

E. Cutaneous:

Cutaneous pain arises from the skin or subcutaneous tissues and is often described as superficial, sharp, or burning.

While the client's leg pain may involve cutaneous innervation, the description provided ("like an electric shock") suggests involvement of deeper structures and neuropathic pain mechanisms rather than purely cutaneous pain.

Therefore, cutaneous pain may not fully capture the nature of the client's pain experience in this scenario.

A. the person experiencing the pain is the authority about the pain. B. administering analgesics for pain will eventually lead to addiction. C. behavioral signs are always congruent with statements about pain. D. the extent of pain is directly related to the amount of tissue damage.

Correct Answer is A

Explanation

A. The person experiencing the pain is the authority about the pain: This is the most important principle to recognize when caring for a patient in pain. Pain is a subjective experience, and the individual experiencing it is the best authority on their pain. Nurses should listen to and respect the patient's descriptions and assessments of their pain, as they are the ones experiencing it firsthand. This principle underscores the importance of patient-centered care and empowers patients to participate in decisions about pain management.

B. Administering analgesics for pain will eventually lead to addiction: While concerns about addiction are important to consider when administering analgesics, this statement is not the most important principle to recognize when caring for a patient in pain. Fear of addiction should not overshadow the patient's right to adequate pain relief. Nurses should prioritize effective pain management while also considering factors such as the patient's history of substance use and monitoring for signs of misuse or addiction.

C. Behavioral signs are always congruent with statements about pain: While behavioral signs can provide valuable information about a patient's pain experience, they may not always be congruent with verbal statements about pain. Some patients may exhibit stoic behaviors despite experiencing significant pain, while others may express distress more visibly. Nurses should consider both verbal and non-verbal cues when assessing pain and tailor interventions accordingly.

D. The extent of pain is directly related to the amount of tissue damage: While pain often accompanies tissue damage or injury, the extent of pain experienced by an individual is influenced by various factors beyond just tissue damage. Pain perception is subjective and can be influenced by factors such as psychological, emotional, cultural, and social factors. Therefore, pain intensity may not always directly correlate with the amount of tissue damage present.

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The nurse is caring for a client who has kidney disease. The client has urinated 250 mL over the past 24 hours. The nurse describes this urine output as:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","C","D"]

Explanation

When caring for a patient in pain, the most important principle that the nurse must recognize is that:

Correct Answer is A

Explanation

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