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 D
Explanation
Choice A reason: While blood pressure is important, hyperkalemia can cause cardiac dysrhythmias, making the pulse rate the first assessment to ensure the patient's immediate safety.
Choice B reason: Temperature is not directly affected by serum potassium levels and is not the priority in hyperkalemia.
Choice C reason: Respirations are less likely to be affected immediately by hyperkalemia compared to cardiac function.
Choice D reason: A high serum potassium level can lead to life-threatening cardiac arrhythmias, so assessing the pulse rate is the most critical initial action.
Correct Answer is A
Explanation
Choice A reason: Level of consciousness is the most basic and sensitive indicator of altered brain function and is considered the most reliable indicator of neurologic status.
Choice B reason: Temperature is not a direct indicator of neurologic status and does not change as rapidly in response to neurologic events.
Choice C reason: Blood pressure can be affected by neurologic changes, but it is not as sensitive or specific as the level of consciousness.
Choice D reason: Pulse rate is not a direct indicator of neurologic status and can be influenced by a variety of non- neurologic factors.
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