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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Mixing the dextrose in a 50 mL piggyback for a total volume of 100 mL is not the appropriate method for administering the medication. This would dilute the dextrose, reducing its concentration and potentially making it less effective.
Choice B rationale
Diluting the dextrose in one liter of 0.9% normal saline solution is not the appropriate method for administering the medication. This would significantly dilute the dextrose, reducing its concentration and potentially making it less effective.
Choice C rationale
Requesting the pharmacist to add the dextrose to a total parenteral nutrition (TPN) solution is not the appropriate method for administering the medication. While dextrose is often a component of TPN solutions, in this case, the patient requires a concentrated dose of dextrose to treat insulin shock.
Choice D rationale
This is the correct answer. Administering the undiluted dextrose slowly through the currently infusing IV is the appropriate method for administering the medication. This allows for the rapid administration of a concentrated dose of glucose, which is necessary to quickly raise the patient’s blood glucose level in the case of insulin shock.
Correct Answer is B
Explanation
Choice A rationale
Reinforcing the connection of the chest tube to the container with tape is not the immediate action to be taken when a client becomes suddenly short of breath and anxious. This action might be necessary if the connection between the chest tube and the container is loose, but it does not address the immediate need of the client.
Choice B rationale
If a client with a chest tube becomes suddenly short of breath and anxious, the nurse should immediately clamp the chest tube with a plastic clamp. This is because the chest tube might have been disconnected from the water seal chamber, and clamping the tube can prevent air from entering the pleural space and causing a tension pneumothorax.
Choice C rationale
Applying an occlusive dressing over the site of the chest tube is not the immediate action to be taken when a client becomes suddenly short of breath and anxious. This action might be necessary if the chest tube is accidentally removed, but it does not address the immediate need of the client.
Choice D rationale
Ensuring that the chest tubing is neither kinked nor hanging low is an important part of the ongoing care for a client with a chest tube, but it is not the immediate action to be taken when a client becomes suddenly short of breath and anxious.
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