A nurse is providing care for a client who is 1-day postoperative following a below-the-knee amputation resulting from musculoskeletal trauma. Which of the following actions should the nurse take?

Discontinue the overhead trapeze.

Turn the client every 6 hr while in bed.

Remind the client that phantom limb pain does not need treatment.

Assist the client to a prone position every 3 hr.

Answer and Explanation

The Correct Answer is D

A) Discontinue the overhead trapeze:
The overhead trapeze can be beneficial for the client to assist with repositioning and mobility, especially postoperatively. Removing it would hinder the client's ability to move independently and could increase the risk of complications from immobility.

B) Turn the client every 6 hr while in bed:
Turning the client every 6 hours is insufficient for preventing complications such as pressure ulcers. Standard care involves repositioning the client at least every 2 hours to maintain skin integrity and promote circulation.

C) Remind the client that phantom limb pain does not need treatment:
Phantom limb pain is a real and often distressing condition for many amputees. It requires appropriate treatment and management strategies to ensure the client's comfort and psychological well-being. Dismissing the pain can lead to increased distress and hinder recovery.

D) Assist the client to a prone position every 3 hr:
Positioning the client in a prone position regularly helps prevent contractures, particularly hip flexion contractures, which are common after lower limb amputations. This position can stretch the hip muscles and aid in maintaining proper alignment and mobility, making it a beneficial intervention in postoperative care.

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Correct Answer is ["B","C","E"]

Explanation

A) Urticaria:
Urticaria, or hives, is a skin reaction characterized by itchy, raised welts. It is not typically associated with a small bowel obstruction, which primarily affects the gastrointestinal system rather than the skin.

B) Vomiting:
Vomiting is a common symptom of a complete small bowel obstruction. It occurs due to the blockage in the intestines, which prevents the passage of contents, leading to nausea and vomiting as the body tries to expel the obstruction.

C) Distended abdomen:
A distended abdomen is expected in cases of small bowel obstruction. The blockage causes a buildup of gas and fluids, leading to abdominal swelling and distention as the normal passage of intestinal contents is impeded.

D) Fluid overload:
Fluid overload is not a typical manifestation of a small bowel obstruction. Instead, dehydration and electrolyte imbalances are more likely due to vomiting and the inability to absorb fluids and nutrients properly.

E) Obstipation:
Obstipation, or severe constipation with an inability to pass stool or gas, is a key sign of a complete small bowel obstruction. The obstruction prevents the normal movement of intestinal contents, leading to a cessation of bowel movements.

A. "What are you looking forward to each day?" B. "Can you tell me about your sleep patterns?" C. "Have you ever felt like you don't want to live anymore?" D. "Are you taking any medications at this time?"

Correct Answer is C

Explanation

A) "What are you looking forward to each day?": While asking about daily expectations can provide insight into the client's coping mechanisms and hopefulness, it does not immediately address potential safety concerns. It is a helpful question for assessing the client's adjustment but not the priority if there is a concern about suicidal ideation.

B) "Can you tell me about your sleep patterns?": Sleep patterns are important for understanding overall well-being, especially during grief. However, this question is secondary to addressing the immediate risk of self-harm. Assessing sleep can come after determining if the client is having suicidal thoughts.

C) "Have you ever felt like you don't want to live anymore?": This question is crucial because it directly assesses the client's risk of suicidal ideation or self-harm. Given the client's recent loss and current symptoms, it is important to evaluate if there is a risk to their safety, making this the priority question.

D) "Are you taking any medications at this time?": While it is important to know about the client's medication use, this question does not address the immediate risk of self-harm or assess the psychological impact of the recent loss. Medication information is less urgent compared to evaluating suicidal thoughts.

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A nurse is providing care for a client who is 1-day postoperative following a below-the-knee amputation resulting from musculoskeletal trauma. Which of the following actions should the nurse take?

Nursing Test Bank

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Explanation

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