A nurse is caring for a child who is 3 days postoperative following a below-the-knee amputation of the left leg.
Which of the following actions should the nurse take first?
Reinforce teaching about phantom limb pain to the child.
Inspect the skin at the incision site for manifestations of infection.
Perform range-of-motion exercises to the affected extremity.
Assist in placing the child in the prone position three times a day.
The Correct Answer is B
Choice A rationale
Phantom limb pain education is important but not an immediate priority. It focuses on post-amputation sensation caused by disrupted nerve signals. However, addressing complications like infection is crucial in the immediate postoperative phase to prevent further morbidity.
Choice B rationale
Inspecting the incision site prioritizes infection control. Early signs of infection such as erythema, warmth, or exudate must be addressed immediately to prevent systemic spread. Postoperative infections can impede healing and increase hospital stay. This action directly impacts the child's recovery.
Choice C rationale
Range-of-motion exercises are vital in the long-term rehabilitation phase to prevent contractures. However, these exercises do not address immediate concerns like postoperative infection, making them a secondary priority in acute care.
Choice D rationale
The prone position helps prevent hip flexion contractures in patients post-lower extremity amputation. While essential for long-term musculoskeletal health, this action is not the most critical during the acute recovery phase when infection is a larger concern.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Increased weight-bearing ability on the affected leg is typically an expected finding, especially as the client begins to recover postoperatively. Enhanced weight-bearing suggests improving strength, mobility, and healing in the affected limb. It does not usually indicate complications. As such, this finding does not necessitate reporting unless accompanied by other concerning symptoms, such as significant pain or changes in circulation.
Choice B rationale: Warmth extending from the left calf to the knee could indicate localized inflammation or infection. However, warmth alone is not definitive for conditions like deep vein thrombosis (DVT) or cellulitis. Without additional findings such as swelling, redness, or pain, it may not be immediately concerning. Nevertheless, it warrants monitoring as a precaution, particularly in postsurgical clients at risk for complications like DVT.
Choice C rationale: A temperature of 38.8° C (101.8° F) is above the normal range of 36.1° C to 37.2° C (97.0° F to 99.0° F) and suggests the possibility of a systemic infection, such as a postoperative wound infection. This finding is significant and must be reported promptly to the healthcare provider for further evaluation and intervention. Early detection and treatment of infections are crucial to prevent complications like sepsis.
Choice D rationale: Itching in bilateral antecubital spaces is a nonspecific symptom that may be attributed to a mild allergic reaction, irritation, or dryness of the skin. While it could indicate a reaction to medications or adhesives used during surgery, it is generally not an urgent concern unless accompanied by additional symptoms like rash, swelling, or respiratory distress. Close monitoring is recommended rather than immediate reporting.
Correct Answer is A
Explanation
Choice A rationale
Adolescents in many jurisdictions, including Kenya, may consent to treatment for sexually transmitted infections without parental involvement to promote public health and confidentiality. This legal provision ensures that they access necessary care without fear of stigma. Furthermore, informed consent requires the individual to comprehend the purpose and implications of the treatment, which most 16-year-olds can demonstrate for issues related to STIs.
Choice B rationale
A guidance counselor does not have legal authority to provide informed consent for medical treatment. Their role is to offer emotional and academic support rather than making medical decisions. Informed consent must be given by someone authorized by law, which excludes guidance counselors in this context.
Choice C rationale
The medical care provider's responsibility is to obtain informed consent rather than give it. Their role involves ensuring the patient understands the nature of the treatment, its risks, and benefits. They cannot act as a proxy for the client in providing legal consent.
Choice D rationale
Adult relatives, unless they are legal guardians, do not hold authority to provide informed consent for medical treatment of minors. Even in familial relations, consent laws require specific legal designations to act on behalf of a minor unless otherwise stated by the law.
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