A nursing is planning care for an adolescent who is postoperative following scoliosis repair with Harrington rod instrumentation. Which of the following interventions should the nurse include in the plan of care?
Place the client in protective isolation.
Initiate the use of a PCA pump for pain control.
Keep the head of the bed at a 30° angle.
Reposition the client by log rolling every-4 hr.
The Correct Answer is D
A. Protective isolation is not routinely required for clients following scoliosis repair unless there is an underlying infection risk.
B. A PCA pump may be used for pain control, but it is not specific to post-scoliosis repair care.
C. Keeping the head of the bed at 30° is not required; positioning should focus on spinal alignment.
D. Log rolling the client every 4 hours is essential to maintain spinal alignment, prevent complications, and ensure safety following Harrington rod instrumentation.
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Related Questions
Correct Answer is A
Explanation
A. "Your pain will gradually become less severe." This statement is accurate and provides realistic expectations for the client. After an amputation, there will be initial post operative pain, but it should gradually decrease over time.
B. "The pain will disappear soon." This statement is not accurate. While the pain will eventually decrease, it may not completely disappear immediately after the procedure.
C. "It's likely that you will have only a tingling sensation." This statement is not accurate. While some clients may experience tingling sensations, it is not the only sensation they may feel, and this statement does not cover the full range of possible experiences.
D. "Phantom pain is mostly psychological." This statement is not accurate. Phantom pain is a real sensation that some individuals experience after an amputation. It is believed to be related to nerve endings that continue to send signals to the brain even though the limb is no longer present. It is not purely psychological.
Correct Answer is C
Explanation
A. Looseness of the stump dressing may indicate the need for adjustment, but it is not a complication in itself.
B. The dressing forming a cone shape over the stump is a not sign of complications.
C. Pitting edema around the stump dressing may indicate swelling, which is common after an amputation. It is important to monitor for excessive edema as it is a sign of potential complication.
D. Figure-eight wrapping around the stump is a technique used to provide even pressure and support, helping to prevent edema and promote healing. It is not a complication.
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