A client in the PACU with a left below-the-knee amputation complains of pain in her left big toe. Which of the following would the nurse do first?
Show the patient that her leg is gone
Administer the prescribed pain medication
Explain and educate the patient that the pain is real
Tell the patient that it is not possible to feel pain in her toes
The Correct Answer is B
Choice A reason: Showing the patient that her leg is gone does not address the immediate concern of pain management.
Choice B reason: Administering the prescribed pain medication is the first step in managing phantom pain, which is a common experience for amputees.
Choice C reason: While it is important to validate the patient's experience of pain, the first action should be to address the pain medically.
Choice D reason: Telling the patient that it is not possible to feel pain in her toes is incorrect and dismissive of the phenomenon of phantom pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason : Maintenance chemotherapy is not typically used to maintain remission in Hodgkin's lymphoma after successful treatment.
Choice B reason : Follow-up appointments are crucial for monitoring any signs of recurrence or secondary malignancies, as well as managing long-term effects of treatment.
Choice C reason : The potential impact of chemotherapy on fertility is an important topic, especially for younger patients, but may not be as relevant for a 55-year-old woman.
Choice D reason : Addressing symptoms like pruritus, which can persist after treatment, is important for patient comfort and quality of life.
Correct Answer is C
Explanation
Choice A reason : While maintaining a stable ECG rhythm is important, it is not the highest priority. The primary concern is to address life-threatening complications.
Choice B reason : Educating the patient about the causes and effects of coronary heart disease (CHD) or coronary artery disease (CAD) is important for long-term management but is not the immediate priority during acute care.
Choice C reason : Adequate relief of pain is the highest priority in the care of a patient with AMI. Pain is an indicator of ongoing ischemia and can increase the workload of the heart, thereby worsening the condition.
Choice D reason (AMI): While bedrest is part of the care plan, it is not the highest priority compared to pain relief, which has direct implications on the patient's immediate physiological status.
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