While performing hygiene care for a client, a nurse notices a frayed electrical cord on the client’s electronic blood pressure monitor.
Which of the following actions should the nurse take first?

The correct answer is choice C. The client who says “I need to learn how to perform a dressing change on my leg” is indicating an acceptance of the limb loss and a readiness to learn self-care skills.

This is a positive sign of coping and adaptation after an amputation surgery.

Choice A is wrong because the client who says “I am going to have to find someone who can take care of my leg at home” is expressing dependency and denial of the limb loss.

The client needs to be encouraged to participate in self-care activities and rehabilitation.

Choice B is wrong because the client who says “I stay awake at night because I keep thinking about my leg” is experiencing phantom limb sensation, which is a common phenomenon after amputation.

The client may benefit from pain management, distraction techniques, and counseling.

Choice D is wrong because the client who says “I know my family means well, but I don’t want visitors seeing my leg right now” is showing signs of social isolation and low self-esteem.

The client needs emotional support and reassurance from the nurse and family members.

Normal ranges for vital signs after amputation are blood pressure 120/80 mm Hg, pulse 60-100 beats/min, respiratory rate 12-20 breaths/min, and temperature 36.5-37.5°C.

The correct answer is choice D. The nurse should respect the client’s autonomy and offer assistance if needed.

The nurse should also assess the client’s pain level and provide adequate pain relief before helping the client get out of bed.

Choice A is wrong because it implies that the client is in pain and needs medication, which may not be true.

The nurse should ask the client about their pain level and offer medication if appropriate.

Choice B is wrong because it dismisses the client’s feelings and does not address the underlying issue of why the client does not want to be touched.

Choice C is wrong because it may make the client feel defensive or interrogated.

The nurse should use open-ended questions and active listening to explore the client’s concerns and fears.

According to web sources, postoperative care involves monitoring and managing the client’s vital signs, pain, wound healing, fluid and electrolyte balance, bowel and bladder function, mobility, and psychological status.

The nurse should also educate the client about self-care, wound care, activity restrictions, medication use, signs of complications, and follow-up appointments.

The nurse should also provide emotional support and reassurance to the client and their family.