The nurse is caring for a client who is postoperative following a right below-the-knee amputation. The client asks the nurse, " I keep having pain in my right foot. Why is that?" Which response would be appropriate for the nurse to make?

“There is some swelling in your right leg that is making you feel this way."

"Your brain is responding to being inactive from the surgery."

"Don't worry about your right foot. The pain will go away within a few days."

"Your brain is still receiving impulses about your right foot."

Answer and Explanation

The Correct Answer is D

A. “There is some swelling in your right leg that is making you feel this way.” Swelling would typically cause discomfort or pressure, but it would not be responsible for the sensation of pain in the amputated limb.

B. "Your brain is responding to being inactive from the surgery." This answer does not address the real cause of the pain, which is related to the brain's continued perception of the missing limb.

C. "Don't worry about your right foot. The pain will go away within a few days." Phantom limb pain is a common phenomenon after amputation and may persist long-term. Dismissing it is not appropriate.

D. "Your brain is still receiving impulses about your right foot." This is an accurate explanation for phantom limb pain. After amputation, the brain may still interpret sensations from the absent limb, causing pain or discomfort in the "missing" foot.

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Correct Answer is B

Explanation

A. Junctional tachycardia: Junctional tachycardia originates from the atrioventricular (AV) node, with a faster rate and usually no visible P waves preceding the QRS complexes.

B. Sinus tachycardia: Sinus tachycardia is characterized by a regular, rapid heart rhythm originating from the sinus node, typically seen after exercise, with identifiable P waves before each QRS complex.

C. Atrial flutter: Atrial flutter presents with a “sawtooth” pattern of P waves, indicating rapid atrial contractions, which is different from sinus tachycardia.

D. Ventricular fibrillation: Ventricular fibrillation is a chaotic and irregular rhythm originating from the ventricles, which is a life-threatening condition.

A. Deficits in the right visual field B. Motor retardation C. Poor impulse control D. Unable to discriminate words and letters

Correct Answer is C

Explanation

A. Deficits in the right visual field: This would be associated with a left-sided stroke, as the right hemisphere controls the left visual field.

B. Motor retardation: This is not a specific sign of right hemisphere stroke. It might be seen with other types of strokes.

C. Poor impulse control: A right hemisphere stroke may cause behavioral changes, including impulsivity, poor judgment, and difficulty in regulating emotions.

D. Unable to discriminate words and letters: This would suggest aphasia, which is typically associated with left hemisphere damage, as the left hemisphere controls language.

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The nurse is caring for a client who is postoperative following a right below-the-knee amputation. The client asks the nurse, " I keep having pain in my right foot. Why is that?" Which response would be appropriate for the nurse to make?

Nursing Test Bank

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Correct Answer is B

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Correct Answer is C

Explanation

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