The nurse is caring for a patient who underwent an above-the-knee amputation. What is the priority nursing intervention to prevent hip flexion contractures?
Performing passive range of motion exercises to the hip joint
Elevating the residual limb on a pillow
Administering analgesics as prescribed
Providing emotional support and counseling
The Correct Answer is A
The priority nursing intervention to prevent hip flexion contractures after an above-the-knee amputation is performing passive range of motion exercises to the hip joint. Contractures are abnormal shortening and tightening of muscles and tendons, leading to restricted joint movement. Passive range of motion exercises help maintain joint flexibility and prevent contractures.
b. Elevating the residual limb on a pillow: Elevating the residual limb on a pillow is more applicable for preventing swelling and edema, not specifically for preventing hip flexion contractures.
c. Administering analgesics as prescribed: While pain management is essential for the patient's comfort, it is not directly related to preventing hip flexion contractures.
d. Providing emotional support and counseling: Emotional support and counseling are important aspects of care but are not directly related to preventing hip flexion contractures.
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Correct Answer is C
Explanation
Acute osteomyelitis is a severe bacterial infection of the bone that can lead to tissue damage and the spread of infection if not promptly treated. In some cases, when antibiotic therapy is not effective or the infection is severe, amputation may be considered to remove the infected bone and prevent further complications.
a. Severe joint pain: Severe joint pain may be caused by various conditions, but it is not an indication for amputation. Treatment for joint pain involves identifying and managing the underlying cause.
b. Chronic osteoporosis: Osteoporosis is a condition characterized by weakened bones, but it does not typically lead to amputation. Treatment for osteoporosis focuses on preventing fractures and improving bone density through medication and lifestyle modifications.
d. Muscle strain: Muscle strains are common injuries that do not require amputation. They can usually be managed with rest, ice, compression, and elevation (RICE) and physical therapy.
Correct Answer is D
Explanation
The priority nursing intervention in the immediate post-operative period after an upper extremity amputation is to assess the surgical incision for infection. Early detection of signs of infection, such as redness, swelling, warmth, or drainage, is crucial to prevent complications and promote healing.
a. Managing phantom limb pain: While managing phantom limb pain is important, it may not be the priority nursing intervention immediately after the surgery. Assessing the surgical incision for infection and monitoring for any complications take precedence.
b. Ensuring proper prosthetic fitting: Prosthetic fitting is essential for functional outcomes, but it may not be the priority in the immediate post-operative period. It is addressed during the rehabilitation phase.
c. Elevating the residual limb on a pillow: Elevating the residual limb on a pillow is typically recommended for lower extremity amputations to reduce edema and promote venous return, not for upper extremity amputations.
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