The nurse is providing postoperative care for an adolescent who underwent a left leg amputation due to osteosarcoma.

The adolescent reports experiencing phantom limb pain.

Which non-pharmacological intervention should the nurse provide?

Reassure that this can be a normal post-surgical sensation.

Guide in moving the non-affected limb to override the sensation being experienced.

Explain that the sensations of tingling and pain are not real.

Affirm that a prosthetic with physical therapy will gradually improve the symptoms.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Reassuring the adolescent that experiencing phantom limb pain can be a normal post-surgical sensation is the correct choice. Phantom limb pain is a common occurrence after amputation and can be very distressing for the patient. The nurse should validate the patient’s experience and provide reassurance. Non-pharmacological interventions such as mirror therapy, visualization, and other cognitive-behavioral strategies can also be helpful.

Choice B rationale
Guiding the patient in moving the non-affected limb to override the sensation being experienced is not the most appropriate intervention. While some therapies for phantom limb pain involve focusing on the remaining limb, this should be done under the guidance of a trained therapist.

Choice C rationale
Telling the patient that the sensations of tingling and pain are not real is not an appropriate intervention. Although the limb is no longer there, the pain that the patient is experiencing is very real. It is important to validate the patient’s experience and provide appropriate interventions.

Choice D rationale
Affirming that a prosthetic with physical therapy will gradually improve the symptoms is not the most appropriate intervention. While using a prosthetic and engaging in physical therapy can help with overall recovery and adaptation after amputation, they do not directly address phantom limb pain. The pain is a result of mixed signals from the brain and nerves, and it requires specific interventions.

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Correct Answer is A

Explanation

Choice A rationale
Testing the fluid on the dressing for glucose is the immediate course of action when a nurse notices clear fluid on the surgical dressing of a patient who has just returned from lumbar spinal surgery. Clear fluid could be cerebrospinal fluid (CSF), which contains glucose. If the fluid is positive for glucose, it could indicate a CSF leak, which requires immediate medical attention.
Choice B rationale
Changing the dressing using a compression bandage is not the immediate course of action. The source of the fluid needs to be identified first.
Choice C rationale
Marking the drainage area with a pen and continuing to monitor is not the immediate course of action. The source of the fluid needs to be identified first.
Choice D rationale
Documenting the findings in the electronic medical record is important, but it is not the immediate course of action. The source of the fluid needs to be identified first.

A. Stabilize the cervical spine. B. Check for a pulse. C. Request an x-ray. D. Assess the respiratory rate. E. Examine the abdomen. F. Ensure the airway is patent.

Correct Answer is ["A","F"]

Explanation

Choice A rationale

Stabilizing the cervical spine is one of the first actions that should be taken during the primary survey of a trauma patient. This is to prevent any potential injury to the spinal cord, which could result in permanent paralysis.

Choice B rationale
Checking for a pulse is an important part of the primary survey, but it is not one of the first actions that should be taken. The first priority is to ensure that the airway is patent and the cervical spine is stabilized.

Choice C rationale
Requesting an x-ray is not one of the first actions that should be taken during the primary survey. The first priority is to assess the client’s airway, breathing, and circulation, and to stabilize the cervical spine.

Choice D rationale
Assessing the respiratory rate is an important part of the primary survey, but it is not one of the first actions that should be taken. The first priority is to ensure that the airway is patent and the cervical spine is stabilized.

Choice E rationale
Examining the abdomen is an important part of the secondary survey, which is conducted after the primary survey. The first priority during the primary survey is to assess the client’s airway, breathing, and circulation, and to stabilize the cervical spine.
Choice F rationale

Ensuring that the airway is patent is one of the first actions that should be taken during the primary survey. This is to ensure that the client is able to breathe effectively and receive adequate oxygenation.

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The nurse is providing postoperative care for an adolescent who underwent a left leg amputation due to osteosarcoma. The adolescent reports experiencing phantom limb pain. Which non-pharmacological intervention should the nurse provide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse notices clear fluid on the surgical dressing of a patient who has just returned from lumbar spinal surgery. What should be the nurse’s immediate course of action?

Correct Answer is A

Explanation

The client is a 26-year-old female who fell from an apartment balcony. She was transported to the hospital via ambulance. The client enters the emergency room on a stretcher and is met in the trauma bay by the nurse. What two actions should the nurse take first during the primary survey?

Correct Answer is ["A","F"]

Explanation

While conducting an admission assessment of a female client with bipolar disorder, the client suddenly starts to undress and throw her clothes around the room. What should be the nurse’s initial action?

An adolescent arrives at the emergency department (ED) with a fever and persistent lower right quadrant abdominal pain. The patient is anxious, fearful, and hyperventilating. What acid-base imbalance does the nurse anticipate the patient will develop?

The nurse observes an unlicensed assistive personnel (UAP) preparing to provide personal care for a patient who requires contact precautions. The UAP has put on a gown and gloves and has secured the tops of the gloves over the gown sleeves. What action should the nurse take?

Which assessment finding is most crucial when planning to provide a complete bed bath to a bedfast client?

A patient admitted to the hospital with a suspected ruptured diverticulum develops signs and symptoms of septic shock. The healthcare provider prescribes a sepsis protocol. Which intervention is most important for the nurse to include in the plan of care?

The nurse is providing postoperative care for an adolescent who underwent a left leg amputation due to osteosarcoma.

The adolescent reports experiencing phantom limb pain.

Which non-pharmacological intervention should the nurse provide?