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: An embolic stroke is caused by an embolus traveling to the brain and blocking a blood vessel. The symptoms described do not specifically indicate an embolic stroke.
Choice B reason: A hemorrhagic stroke, which is bleeding within the brain, often presents with a sudden, severe headache, vomiting, and a change in consciousness, aligning with the symptoms described.
Choice C reason: A thrombotic stroke is caused by a thrombus forming in a blood vessel in the brain. While it can cause similar symptoms, the sudden severe headache is more characteristic of a hemorrhagic stroke.
Choice D reason: A transient ischemic attack (TIA) is a temporary blockage of blood flow to the brain. The symptoms usually resolve within minutes to hours and do not typically include a severe headache or vomiting.
Correct Answer is A
Explanation
Choice A reason: Packed RBCs should be transfused as soon as possible once the nurse has prepared everything necessary for the transfusion.
Choice B reason: Waiting 2 hours after obtaining the blood is not necessary and could delay needed treatment.
Choice C reason: The client's mealtime should not delay the transfusion of blood, which is a time-sensitive medical treatment.
Choice D reason: While the client's readiness is important, it should not unduly delay the transfusion if the client is medically stable and the transfusion is necessary.
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