A nurse at a rehabilitation facility is contributing to the plan of care for a client who has had a below-the-knee amputation. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

Restrict visitors to family members until the client is able to wear a prosthesis.

Encourage the client to talk with another client who completed rehabilitation for amputation.

Instruct the client to ignore phantom pain sensations.

Suggest that family members bring clothing for the client from home.

Ask the client to describe her feelings about the loss of the affected limb.

Answer and Explanation

Correct Answer : B,D,E

A. Restrict visitors to family members until the client is able to wear a prosthesis: Restricting visitors may increase isolation and hinder emotional support.
B. Encourage the client to talk with another client who completed rehabilitation for amputation: Peer support can provide emotional reassurance and motivate the client in their recovery process.
C. Instruct the client to ignore phantom pain sensations: Phantom pain is real and should not be dismissed; it requires management through medication or other interventions.
D. Suggest that family members bring clothing for the client from home: Familiar clothing can improve self-esteem and promote adjustment to body image changes.
E. Ask the client to describe her feelings about the loss of the affected limb: Exploring the client’s feelings helps address emotional and psychological aspects of coping with amputation.

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Correct Answer is B

Explanation

A. Administer a glycerin suppository: While this may help, addressing bowel hypoactivity through ambulation is less invasive and more appropriate initially.
B. Ambulate the client in the hallway. Ambulation stimulates peristalsis, which can help resolve hypoactive bowel sounds and abdominal discomfort, making it the priority action.
C. Request the client to be NPO: Making the client NPO might be necessary later if symptoms worsen or there is suspicion of ileus or obstruction, but it is not the first action.
D. Offer an analgesic medication: Pain relief is essential, but analgesics (especially opioids) can worsen bowel hypoactivity. Prioritize interventions that restore bowel function first.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

The first action the nurse should take is to assess neurovascular status followed by notify the provider.

Assess neurovascular status first: The diminished pulses and coolness of the right foot indicate compromised circulation, requiring immediate evaluation to confirm the severity.
Notify the provider: Once the critical assessment findings are confirmed, notifying the provider for prompt intervention is essential to prevent further complications.

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A nurse at a rehabilitation facility is contributing to the plan of care for a client who has had a below-the-knee amputation. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 2 days postoperative following abdominal surgery. The nurse auscultates hypoactive bowel sounds, and the client reports cramping abdominal pain. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

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