The nurse reviews the client's test results.

Exhibits

For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

A. Encourage the client to use the overbed trapeze. Using an overbed trapeze helps the client build upper body strength, which is essential for mobility and independence following an amputation. Strengthening the arms and shoulders facilitates bed mobility, transfers, and eventual prosthetic use.
B. Keep a loose, absorbent dressing over the client's surgical site. The surgical site should be covered with a secure, sterile dressing to promote healing and prevent infection. Loose dressings can shift, increasing the risk of contamination and delayed wound healing.
C. Maintain abduction of the client's residual limb with a pillow. Prolonged abduction is not recommended, as it can lead to hip contractures. The limb should be kept in a neutral or slightly extended position to maintain proper alignment and prevent muscle shortening that could interfere with prosthetic use.
D. Caution the client to avoid a prone position while in bed. Prone positioning is actually encouraged intermittently to help stretch the hip flexors and prevent contractures. Avoiding this position may increase the risk of hip flexion contractures, making prosthetic fitting and ambulation more difficult.

A. Measure the duration of the seizure. Monitoring the duration of a seizure is critical in determining whether it is self-limiting or prolonged. Seizures lasting longer than five minutes may indicate status epilepticus, requiring emergency intervention. Documenting the start and end times helps guide appropriate medical management.
B. Restrain the client's arms and legs to prevent injury. Restraining a client during a seizure can cause musculoskeletal injury or increase agitation. Instead, the nurse should ensure the client is in a safe position, remove nearby hazards, and allow the seizure to run its course while protecting the head.
C. Insert an oral airway into the client's mouth. Forcing an airway device or object into a seizing client's mouth can cause oral trauma, aspiration, or obstruction. The priority is to maintain a patent airway by positioning the client on their side to allow secretions to drain and prevent aspiration.
D. Lower the side rails of the bed when the seizure begins. Lowering the side rails increases the risk of the client falling out of bed during convulsions. If the client is already in bed, keeping the side rails up and padded can help prevent injury while allowing safe observation of the seizure activity.