A nurse is teaching a client who has a prosthetic limb due to a right below-the-knee amputation about prosthesis and stump care. Which of the following instructions should the nurse include in the teaching?

Dry the prosthesis socket completely before applying it to the limb.

Apply a moisturizing lotion or oil to the stump daily.

Keep the prosthesis in direct contact with the residual limb.

Expect some skin irritation from the prosthesis.

Answer and Explanation

The Correct Answer is A

Choice A reason:
It is essential to dry the prosthesis socket completely before applying it to the limb to prevent any moisture-related issues, such as skin irritation or infection. Moisture can create an environment conducive to bacterial growth and can also cause the prosthesis to slip or not fit properly.

Choice B reason:
While it is important to keep the skin of the stump moisturized, applying lotion or oil immediately before putting on the prosthesis is not advised. Lotions and oils can make the skin slippery, leading to a poor fit of the prosthesis or even causing the prosthesis to slip off. It is better to apply moisturizer at a time when the prosthesis will not be worn for a while, allowing the skin to absorb the lotion fully.

Choice C reason:
The prosthesis should not be in direct contact with the residual limb without proper padding or a liner. Direct contact can lead to pressure sores, skin irritation, and discomfort. Properly fitted socks or liners should be used to cushion the limb and ensure a comfortable, secure fit.

Choice D reason:
While some skin irritation may be expected when first using a prosthesis, persistent irritation is not normal and should be addressed by a healthcare provider. The prosthesis may need to be adjusted, or there may be an issue with the fit or the materials used. Skin irritation should not be accepted as a standard part of using a prosthesis.

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Correct Answer is B

Explanation

Choice A reason:
Using an antibiotic ointment is not typically recommended as a preventive measure for skin integrity during radiation therapy. Antibiotic ointments are used to treat bacterial infections, and their use should be directed by a healthcare provider if an infection is present or there is skin breakdown.

Choice B reason:
It is important not to apply heat to the area of irradiation as heat can increase skin irritation and the risk of burns in the treated area. Patients undergoing radiation therapy are advised to avoid heat sources, including heating pads, hot water bottles, and direct sunlight, to prevent further damage to the skin.

Choice C reason:
Lubricating the skin with hypoallergenic lotion can help maintain skin integrity by keeping it moisturized. However, it is crucial to use lotions that are free of metals, alcohol, perfumes, and dyes, as these can react with radiation and cause skin irritation. Lotions should be applied after radiation therapy sessions and not immediately before treatment.

Choice D reason:
The instruction not to wash the area of irradiation is incorrect. It is essential to keep the skin clean to reduce the risk of infection. Patients should gently wash the irradiated area with lukewarm water and mild soap, and pat the area dry with a soft towel. They should avoid scrubbing or using harsh soaps that can irritate the skin.

A. Location of the burn B. Age of the client C. Cause of the burn D. Associated medical history

Correct Answer is A

Explanation

Choice A reason:
The location of the burn is crucial in assessing the severity because burns to the face, neck, and upper extremities can compromise vital functions. For example, burns to the face may affect the airway and respiratory system, while burns to the hands can impair mobility and the ability to perform daily tasks. The depth of the burn at these locations also affects the severity assessment, as deeper burns can damage underlying tissues and structures.

Choice B reason:
While the age of the client can influence the healing process and the risk of complications, it is not the primary factor in assessing the initial severity of the burn. However, age is considered when planning treatment and rehabilitation, as children and the elderly may have different healing rates and responses to therapy.

Choice C reason:
The cause of the burn can provide context for potential complications, such as inhalation injury from a fire or chemical exposure. However, the immediate assessment of severity is more focused on the observable damage to the skin and underlying tissues rather than the cause of the burn.

Choice D reason:
The client's associated medical history is important for understanding potential risks and complications during the healing process, but it is not the primary factor in assessing the severity of the burn. The medical history will be more relevant when considering the client's overall prognosis and planning long-term care.

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A nurse is teaching a client who has a prosthetic limb due to a right below-the-knee amputation about prosthesis and stump care. Which of the following instructions should the nurse include in the teaching?

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