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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: An INR of 0.9 is within the normal range (0.8-1.2) and does not support the presence of bruising or bleeding disorders.

Choice B reason: A hematocrit level of 28% is below the normal range (36%-50% for women, 40%-54% for men), indicating anemia, but it does not directly explain bruising or petechiae.

Choice C reason: A WBC count of 4500 is within the normal range (4500-11000), suggesting that there is no active infection or leukocytosis that would explain the bruising.

Choice D reason: A platelet count of 60000 is below the normal range (150000-450000), which can lead to easy bruising and petechiae, supporting the nurse's observation.

A. Crohn's disease causes continuous inﬂammation of the mucosa and sub-mucosa of the colon and rectal linings. B. Crohn's disease is characterized by a transmural granulomatous inﬂammation that can aﬀect any part of the gastrointestinal tract. C. Crohn's disease looks like what would appear to be a second-degree burn in the colon and rectum areas only. D. Crohn's disease has the appearance of a patchwork quilt with some areas that are clear and some with sores.

Correct Answer is D

Explanation

Choice A reason: This description is too clinical and not the simplest explanation.

Choice B reason: This statement is medically accurate but not the most simplistic description.

Choice C reason: Comparing Crohn's disease to a second-degree burn is not accurate as it does not only aﬀect the colon and rectum.

Choice D reason: Describing Crohn's disease as having the appearance of a patchwork quilt with some areas clear and some with sores provides a simple visual that is easy to understand without medical knowledge.

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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?

Nursing Test Bank

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