The nurse is caring for a client who is postoperative following a right below-the-knee amputation. The client asks the nurse, " I keep having pain in my right foot. Why is that?" Which response would be appropriate for the nurse to make?

“There is some swelling in your right leg that is making you feel this way."

"Your brain is responding to being inactive from the surgery."

"Don't worry about your right foot. The pain will go away within a few days."

"Your brain is still receiving impulses about your right foot."

Answer and Explanation

The Correct Answer is D

A. “There is some swelling in your right leg that is making you feel this way.” Swelling would typically cause discomfort or pressure, but it would not be responsible for the sensation of pain in the amputated limb.

B. "Your brain is responding to being inactive from the surgery." This answer does not address the real cause of the pain, which is related to the brain's continued perception of the missing limb.

C. "Don't worry about your right foot. The pain will go away within a few days." Phantom limb pain is a common phenomenon after amputation and may persist long-term. Dismissing it is not appropriate.

D. "Your brain is still receiving impulses about your right foot." This is an accurate explanation for phantom limb pain. After amputation, the brain may still interpret sensations from the absent limb, causing pain or discomfort in the "missing" foot.

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Correct Answer is A

Explanation

A. Intracranial pressure (ICP) is now 15: Mannitol is an osmotic diuretic used to reduce intracranial pressure (ICP). The intended effect of the medication is to lower ICP. A decrease in ICP to 15 mmHg is within the normal range and indicates the medication has worked effectively.

B. The patient voids 250 mL over 2 hours is incorrect. While mannitol promotes diuresis, the amount of urine output alone does not directly indicate a reduction in ICP. The goal is to lower ICP, which is best assessed by measuring the ICP itself.

C. The patient's pupils are dilated and sluggish is incorrect. Dilated and sluggish pupils can be a sign of increased ICP, not a response to effective treatment.

D. Seizure behavior is absent is incorrect. While mannitol can help reduce ICP and potentially prevent seizures, the absence of seizure behavior is not a direct indicator of the medication's effect on ICP.

A. It indicates a normal depolarization of the atria. B. It provides information about atrial repolarization. C. It shows an early indication of first degree heart block. D. It reflects a delayed conduction through the atria.

Correct Answer is A

Explanation

A. It indicates a normal depolarization of the atria: A PR interval of 0.12–0.20 seconds is within the normal range, representing normal conduction through the atria and AV node.

B. It provides information about atrial repolarization: Atrial repolarization is obscured by the QRS complex and not reflected in the PR interval.

C. It shows an early indication of first-degree heart block: First-degree heart block is indicated by a PR interval longer than 0.20 seconds.

D. It reflects a delayed conduction through the atria: A delay in conduction would result in a prolonged PR interval.

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The nurse is caring for a client who is postoperative following a right below-the-knee amputation. The client asks the nurse, " I keep having pain in my right foot. Why is that?" Which response would be appropriate for the nurse to make?

Nursing Test Bank

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Correct Answer is A

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Correct Answer is A

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