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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
A. Current medication prescriptions: Ensures continuity of care and proper medication administration in the ICU.
B. Primary health problem: Provides the ICU team with context about the client’s current condition and reason for transfer.
C. Number of family members who have visited: This is not clinically relevant to the client's care.
D. Admission vital signs from 1 week ago: Historical vitals are not as critical as current or recent findings.
E. Scheduled times for dressing changes: Provides critical information about ongoing wound care needs.
Correct Answer is A
Explanation
A. The client has an inspiratory stridor. Inspiratory stridor indicates airway obstruction or laryngeal edema, a potentially life-threatening complication following a bronchoscopy that requires immediate intervention.
B. The client reports a sore throat: A sore throat is common after bronchoscopy due to irritation from the scope. This does not require reporting.
C. The client’s sputum has streaks of blood: Small amounts of blood in sputum are expected due to minor mucosal trauma.
D. The client’s temperature is 38.6°C (101.4°F): Mild fever can occur post-procedure due to inflammation but should only be reported if it persists or other infection signs develop.
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