A nurse is assisting in creating a plan to reduce environmental stressors for clients in an acute care unit.
Which of the following actions should the nurse include in the plan?

The correct answer is choice D. Flex hips and knees when assisting the client to a standing position.

Choice A rationale:

Raising the bed to waist level before moving the client is not recommended because it can increase the risk of falls and injuries. The bed should be at a height that allows the nurse to maintain proper body mechanics and ensure the client’s safety during the transfer.

Choice B rationale:

Pivoting on the foot farthest from the bed when assisting the client into the chair is incorrect. The nurse should pivot on the foot closest to the bed to maintain stability and control during the transfer.

Choice C rationale:

Standing on the client’s stronger side when moving the client into the chair is not the best practice. The nurse should stand on the client’s weaker side to provide support and prevent the client from falling towards their weaker side.

Choice D rationale:

Flexing hips and knees when assisting the client to a standing position is correct. This technique helps the nurse maintain proper body mechanics, reduces the risk of injury, and provides better support to the client during the transfer.

The correct answer is choice C. The client who says “I need to learn how to perform a dressing change on my leg” is indicating an acceptance of the limb loss and a readiness to learn self-care skills.

This is a positive sign of coping and adaptation after an amputation surgery.

Choice A is wrong because the client who says “I am going to have to find someone who can take care of my leg at home” is expressing dependency and denial of the limb loss.

The client needs to be encouraged to participate in self-care activities and rehabilitation.

Choice B is wrong because the client who says “I stay awake at night because I keep thinking about my leg” is experiencing phantom limb sensation, which is a common phenomenon after amputation.

The client may benefit from pain management, distraction techniques, and counseling.

Choice D is wrong because the client who says “I know my family means well, but I don’t want visitors seeing my leg right now” is showing signs of social isolation and low self-esteem.

The client needs emotional support and reassurance from the nurse and family members.

Normal ranges for vital signs after amputation are blood pressure 120/80 mm Hg, pulse 60-100 beats/min, respiratory rate 12-20 breaths/min, and temperature 36.5-37.5°C.