Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A client who is recovering from a lower extremity amputation complains of tingling and "shooting" pain in the amputated extremity. The nurse knows that which of the following is true about this type of pain?
A. The pain comes from severed blood vessels in the residual stump.
The pain does not come from severed blood vessels in the residual stump. Phantom limb pain is not caused by the stump itself but rather by the brain’s perception of the missing limb.
B. It is psychosomatic pain that the patient is just imagining.
Phantom limb pain is not psychosomatic. It is a real phenomenon where the brain continues to receive signals from nerves that were previously connected to the amputated limb.
C. It is often treated with adjunct medications such as antiepileptics and antidepressants.
Phantom limb pain is often treated with adjunct medications such as antiepileptics (e.g., gabapentin) and antidepressants (e.g., amitriptyline), which help modify the way the brain processes pain signals.
D. It is somatic pain that always responds well to opioid medications.
While opioid medications can be used for pain management, phantom limb pain often does not respond well to opioids. It typically requires a combination of other treatments, such as those mentioned in C.
This question is an excerpt from Nurse Dive's nursing test bank - ATI N120 Med Surg Proctored Exam. Take the full exam now
Full Explanation
A. The pain does not come from severed blood vessels in the residual stump. Phantom limb pain is not caused by the stump itself but rather by the brain’s perception of the missing limb.
B. Phantom limb pain is not psychosomatic. It is a real phenomenon where the brain continues to receive signals from nerves that were previously connected to the amputated limb.
C. Phantom limb pain is often treated with adjunct medications such as antiepileptics (e.g., gabapentin) and antidepressants (e.g., amitriptyline), which help modify the way the brain processes pain signals.
D. While opioid medications can be used for pain management, phantom limb pain often does not respond well to opioids. It typically requires a combination of other treatments, such as those mentioned in C.
Similar Questions
The nurse is reviewing laboratory results for a client admitted for renal failure and notes the following: Sodium 144 mEq/L and Potassium 6.6 mEq/L. Which of the following should be the priority intervention?
A. Request a CT scan of the head.
A CT scan of the head is not indicated based on the laboratory findings provided. The priority intervention is related to the elevated potassium level.
B. Assess for Chvostek’s sign.
Chvostek’s sign is associated with hypocalcemia (low calcium levels), not hyperkalemia (high potassium levels).
C. Obtain a chest X-ray.
A chest X-ray is not the priority intervention for elevated potassium. The primary concern is the potential for cardiac arrhythmias related to the high potassium level.
D. Obtain a 12-lead ECG.
Hyperkalemia (potassium 6.6 mEq/L) can lead to cardiac arrhythmias. The nurse should obtain a 12-lead ECG to assess for any changes in the heart's electrical activity, which could indicate serious complications like arrhythmias or cardiac arrest.
Full Explanation
A. A CT scan of the head is not indicated based on the laboratory findings provided. The priority intervention is related to the elevated potassium level.
B. Chvostek’s sign is associated with hypocalcemia (low calcium levels), not hyperkalemia (high potassium levels).
C. A chest X-ray is not the priority intervention for elevated potassium. The primary concern is the potential for cardiac arrhythmias related to the high potassium level.
D. Hyperkalemia (potassium 6.6 mEq/L) can lead to cardiac arrhythmias. The nurse should obtain a 12-lead ECG to assess for any changes in the heart's electrical activity, which could indicate serious complications like arrhythmias or cardiac arrest.
A client presents to the emergency department complaining of several days of nausea and vomiting with weakness and dizziness. The client's vital signs are: Pulse 110, BP 88/56, RR 24, SpO2 95% on room air, temperature of 100.2. The client's lung sounds are clear bilaterally. Which of the following IV fluids would the nurse expect to administer?
A. Dextrose in water
Dextrose in water is typically used for hydration and to provide some calories. However, this client is presenting with hypotension (BP 88/56), tachycardia (Pulse 110), and weakness, likely due to fluid loss from vomiting. This client needs fluid resuscitation with a solution that will help restore circulating volume, and Dextrose in water does not contain sodium, which is necessary for fluid balance in this case.
B. 6.45% Sodium Chloride
6.45% Sodium Chloride is a hypertonic saline solution, which would increase the osmolarity of the blood and pull fluid into the bloodstream. This would not be the first choice for this patient, as it could exacerbate dehydration and electrolyte imbalances.
C. 10% Dextrose in water
10% Dextrose in water is also a hypertonic solution that would provide energy but would not adequately address the client's fluid volume deficit or hypotension.
D. 0.9% Sodium Chloride
0.9% Sodium Chloride is normal saline, which is an isotonic solution and is the most appropriate choice for fluid resuscitation in this client. It will help restore circulating blood volume, stabilize blood pressure, and provide the necessary hydration to address the client's symptoms of dehydration.
Full Explanation
A. Dextrose in water is typically used for hydration and to provide some calories. However, this client is presenting with hypotension (BP 88/56), tachycardia (Pulse 110), and weakness, likely due to fluid loss from vomiting. This client needs fluid resuscitation with a solution that will help restore circulating volume, and Dextrose in water does not contain sodium, which is necessary for fluid balance in this case.
B. 6.45% Sodium Chloride is a hypertonic saline solution, which would increase the osmolarity of the blood and pull fluid into the bloodstream. This would not be the first choice for this patient, as it could exacerbate dehydration and electrolyte imbalances.
C. 10% Dextrose in water is also a hypertonic solution that would provide energy but would not adequately address the client's fluid volume deficit or hypotension.
D. 0.9% Sodium Chloride is normal saline, which is an isotonic solution and is the most appropriate choice for fluid resuscitation in this client. It will help restore circulating blood volume, stabilize blood pressure, and provide the necessary hydration to address the client's symptoms of dehydration.
A nurse is preparing to administer 40 mEq of potassium chloride in 45% sodium chloride (NaCl) 500 mL IV to infuse 10 mEq/hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Full Explanation
- Determine the infusion time: The total dose is 40 mEq, and it's being infused at a rate of 10 mEq/hr.
- Therefore, the total infusion time is 40 mEq / 10 mEq/hr = 4 hours.
- Calculate the infusion rate in mL/hr: The total volume is 500 mL, and the infusion time is 4 hours.
- So, the infusion rate is 500 mL / 4 hours = 125 mL/hr.