A nurse is caring for an older client who is recovering from an above the knee amputation surgery. The client states, “I don’t want to live with only one leg. I should have died during the surgery." What is the nurse’s best response?

Your vital signs are good, and you are doing just fine right now.

You will be able to do some of the same things as before you became disabled.

Your children are waiting outside, do you want them to grow up without a father?

This is a big change for you. What support system do you have to help you cope?

Answer and Explanation

The Correct Answer is D

Choice A reason: This response is dismissive and provides false reassurance. By focusing on physical vital signs, the nurse ignores the client's profound emotional and psychological distress. This effectively shuts down communication and prevents the client from expressing their grief over the loss of their limb.

Choice B reason: This response is overly optimistic and may seem unrealistic to a client currently in the acute phase of grief. It minimizes the client's feelings and fails to acknowledge the significant life alteration they are experiencing, which can hinder the development of a therapeutic relationship.

Choice C reason: This is an inappropriate, guilt-inducing response. Using family members to shame a client for their feelings of hopelessness is non-therapeutic and unprofessional. It does not address the client's underlying depression or help them move toward healthy coping mechanisms.

Choice D reason: This is the best response as it utilizes therapeutic communication techniques. It acknowledges the client's feelings ("This is a big change") and shifts the focus to identifying resources and support systems. This encourages the client to talk about their concerns while assessing their coping abilities.

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Correct Answer is C

Explanation

Choice A reason: Pain is a significant concern in partial-thickness burns because the nerve endings remain intact but are exposed and irritated. Managing severe pain is a priority in the emergent phase to reduce the physiological stress response and improve the patient's comfort and cooperation with treatment.

Choice B reason: Laryngeal edema is a critical priority, especially with burns to the head and neck. Inhalation of hot gases or steam can cause rapid airway swelling and obstruction. Ensuring airway patency is the "A" in the ABCs of trauma and burn management during the emergent phase.

Choice C reason: Leukopenia, or a low white blood cell count, is not a primary concern in the first few hours (emergent phase). In fact, the initial stress response often causes a transient increase in white blood cells (leukocytosis). Infection and changes in WBC counts are typically concerns during the later acute phase.

Choice D reason: Fluid volume deficit is a major concern due to the massive shift of fluids from the intravascular to the interstitial space. Aggressive fluid resuscitation is required during the first 24 to 48 hours to prevent burn shock and maintain vital organ perfusion.

A. Creatinine: 0.9 mg/dL (68.6 mcmol/L) B. Sodium: 146 mEq/L (150 mmol/L) C. Lactate: 7 mg/dL (.08 mmol/L) D. White blood cell count: 11,000/mm3 (11 x 109/L)

Correct Answer is C

Explanation

Choice A reason: A creatinine level of 0.9 mg/dL falls within the standard reference range for an adult, indicating preserved renal function and adequate glomerular filtration. While monitoring renal function is vital in shock due to the risk of acute kidney injury, this specific value does not require urgent notification.

Choice B reason: A sodium level of 146 mEq/L represents very mild hypernatremia or a high normal value, depending on the laboratory's specific reference range. While it warrants monitoring of the patient's fluid status and osmolality, it is not an acute indicator of systemic tissue hypoperfusion or imminent circulatory collapse.

Choice C reason: An elevated lactate level is a critical marker of anaerobic metabolism resulting from tissue hypoxia. In shock, inadequate oxygen delivery forces cells to switch from aerobic to anaerobic pathways. A lactate level of 7 mg/dL is significantly elevated, indicating severe systemic hypoperfusion and an increased risk of mortality.

Choice D reason: A white blood cell count of 11,000/mm3 is only slightly above the normal range and can be caused by various factors, including stress or minor inflammation. While it could suggest early infection, it is not as definitive or urgent an indicator of shock severity as lactate.

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A nurse is caring for an older client who is recovering from an above the knee amputation surgery. The client states, “I don’t want to live with only one leg. I should have died during the surgery." What is the nurse’s best response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client during the first few hours post-admission to the burn unit with partial-thickness burns of the trunk and head. Which potential problem is the least concern for the nurse during the emergent phase of the burn injury?

Correct Answer is C

Explanation

A nurse is caring for several clients at risk for shock. Which laboratory value is most important for the nurse to communicate with the primary health care provider?

Correct Answer is C

Explanation

A nurse is caring for an older client who is recovering from an above the knee amputation surgery. The client states, “I don’t want to live with only one leg. I should have died during the surgery." What is the nurse’s best response?

A client suffered a 45 percent total body surface area (TBSA) burn and was intubated. Twelve hours later, bowel sounds are absent in all four abdominal quadrants. Which is the nurse's best action?

A nurse is caring for a client with disseminated intravascular coagulation (DIC). Which medication would the nurse anticipate administering?

A nurse has educated a client on an epinephrine autoinjector. What statement by the client indicates additional instruction is needed?

The nurse is caring for a client diagnosed with rhabdomyolysis with an elevated myoglobin treated with intravenous fluid. Which finding by the nurse indicates the intervention was effective?

The nurse is preparing to perform a sterile dressing change on a client who obtained full-thickness burns on the right leg one week ago. Which intervention would the nurse implement first?

The nurse is caring for a client with septic shock and assesses blood oozing out from the peripheral intravenous site, bleeding gums, and blood in the indwelling urinary catheter bag. Which intervention would the nurse implement first?

A client with suspected sepsis reports to the nurse they have a headache, feel hot, and are having blurry vision. What is the priority action by the nurse?