A nurse is caring for a client who is recovering from an above-the-knee amputation and reports pain in the limb that was removed. How would the nurse respond?
The pain you are feeling does not actually exist.
This type of pain is common and will eventually go away.
Would you like to learn how to use imagery to minimize your pain?
How would you describe the pain that you are feeling?
The Correct Answer is D
Choice A reason: Stating that phantom limb pain “does not actually exist” dismisses the client’s experience. Phantom pain is a real neurological phenomenon where the brain perceives pain from the absent limb due to nerve endings at the stump sending signals to the cortex.
Choice B reason: While phantom limb pain is common post-amputation, stating it will “eventually go away” oversimplifies management. Pain may persist due to neuroplastic changes in the sensory cortex, requiring interventions like medications or therapy, and this response does not address immediate needs.
Choice C reason: Offering imagery is a valid pain management strategy, as it can modulate pain perception via cognitive distraction. However, it assumes the pain’s nature without assessing its characteristics, which is critical for tailoring interventions like medications or nerve blocks.
Choice D reason: Asking the client to describe phantom limb pain allows the nurse to assess its quality, intensity, and triggers. This informs targeted interventions, as phantom pain results from nerve sensitization and cortical reorganization, requiring a combination of pharmacological (e.g., gabapentin) and non-pharmacological approaches.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Uncemented hip arthroplasty requires careful transfer to prevent dislocation of the new joint, which relies on bone ingrowth for stability. Adequate help (e.g., two staff members) ensures safe transfer, minimizing stress on the surgical site and reducing the risk of falls or prosthesis misalignment.
Choice B reason: Providing socks to “slide easier” increases the risk of slipping during transfer, which could lead to falls or hip dislocation. Non-slip footwear is preferred to ensure stability and safety during mobilization post-hip arthroplasty.
Choice C reason: Full weight bearing is typically restricted after uncemented hip arthroplasty to allow bone ingrowth into the prosthesis. Informing the patient that full weight bearing is allowed is incorrect and could lead to implant failure or dislocation.
Choice D reason: Using a footstool to elevate the leg during transfer is inappropriate, as it may cause hip flexion beyond 90 degrees, increasing the risk of dislocation. Elevation is used in specific positions but not during initial transfers.
Correct Answer is D
Explanation
Choice A reason: Notifying the doctor before taking other medications is correct, as phenytoin interacts with many drugs (e.g., warfarin) via liver enzyme induction (CYP450), altering drug levels. This shows understanding of the need to prevent adverse interactions.
Choice B reason: Scheduling a dental appointment is appropriate, as phenytoin causes gingival hyperplasia due to fibroblast proliferation. Regular dental care prevents gum overgrowth complications, indicating the client understands this side effect and its management.
Choice C reason: Not switching phenytoin brands is correct, as different formulations may have varying bioavailability, affecting seizure control. Consistent branding ensures stable drug levels, reflecting the client’s understanding of maintaining therapeutic efficacy.
Choice D reason: Stating a desire to stop phenytoin suggests a misunderstanding, as seizures often require lifelong antiepileptic therapy to prevent recurrence. Abrupt cessation can cause rebound seizures due to unopposed neuronal excitability, indicating a need for further education.
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