A nurse is caring for a client who is recovering from an amputation of her right arm below the elbow. Which of the following information should the nurse report to the occupational therapist?
The client is allergic to penicillin.
The client's parent is in a skilled nursing facility.
The client has two small children at home.
The client lives in a two-story home.
The Correct Answer is D
A. The client is allergic to penicillin: Medication allergies are critical for the nurse and prescriber to know, but they are not directly relevant to occupational therapy planning.
B. The client's parent is in a skilled nursing facility: While this may influence social support, it is not directly relevant to the client’s rehabilitation needs or adaptive strategies for activities of daily living.
C. The client has two small children at home: Knowing family responsibilities can help plan overall care, but the specific home environment is more critical for occupational therapy interventions.
D. The client lives in a two-story home: The home environment, including stairs, affects mobility, accessibility, and safety after amputation. Reporting this information is essential for planning adaptive equipment, home modifications, and safe discharge.
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Related Questions
Correct Answer is B
Explanation
A. Teach the client relaxation techniques: Teaching coping strategies is helpful but does not address the immediate need to understand the client’s perception of the crisis. It should follow assessment.
B. Confirm the client's perception of the event: The first step in crisis intervention is to assess and understand the client’s view of the situation. Clarifying perception allows the nurse to accurately prioritize interventions and provide appropriate support.
C. Notify the client's support person: Contacting support is beneficial for ongoing assistance but should occur after assessing the client’s understanding and emotional state.
D. Help the client identify personal strengths: Identifying strengths promotes coping and resilience, but it is a secondary intervention that should follow assessment and clarification of the client’s perception.
Correct Answer is B
Explanation
A. Administer calcium gluconate: Calcium gluconate is the antidote for magnesium sulfate toxicity, but it should be given after stopping the infusion and assessing the client’s respiratory status. Immediate discontinuation takes priority.
B. Discontinue the infusion: Difficulty breathing indicates a potential magnesium sulfate toxicity or respiratory depression, which is a life-threatening emergency. The first action is to stop the infusion to prevent further accumulation.
C. Assess the fetal heart rate: Monitoring the fetus is important, but maternal safety takes priority over fetal assessment in a potential toxic reaction. Stabilizing the mother comes first.
D. Obtain the client's magnesium level: Lab assessment is useful for confirming toxicity, but it should not delay immediate intervention. Stopping the infusion takes precedence over obtaining levels.
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