The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendation(s) should the nurse provide this client? (Select all that apply.)

Inspect skin for redness.

Use a residual limb shrinker.

Avoid range of motion exercises.

Apply alcohol to the residual limb after bathing.

Answer and Explanation

Correct Answer : A,B

The correct answer is a. Inspect skin for redness and b. Use a residual limb shrinker.

Choice A rationale:

Inspecting the skin for redness is crucial to identify any signs of infection or pressure sores early. Redness can indicate irritation or the beginning of a pressure ulcer, which needs to be addressed promptly to prevent further complications.

Choice B rationale:

Using a residual limb shrinker helps to reduce swelling and shape the residual limb for prosthetic fitting. It also helps in managing pain and promoting healing by providing consistent compression.

Choice C rationale:

Avoiding range of motion exercises is incorrect. Range of motion exercises are essential to maintain joint flexibility and prevent contractures, which can hinder the use of a prosthetic limb.

Choice D rationale:

Applying alcohol to the residual limb after bathing is not recommended. Alcohol can dry out the skin and cause irritation, which can lead to skin breakdown and infection. Instead, the residual limb should be kept clean and moisturized with appropriate skin care products.

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Correct Answer is ["D","E"]

Explanation

A) Incorrect - Phototherapy, often used to treat conditions like seasonal affective disorder (SAD) or certain skin conditions, involves exposure to specific wavelengths of light. It is not typically used as a treatment for distressing thoughts and memories related to trauma, as described in the client's situation.
B) Incorrect - Lithium is primarily used to treat bipolar disorder and is not a first-line treatment for trauma-related symptoms or acute stress disorder. The client's symptoms are more indicative of trauma-related distress, which would be addressed through psychotherapeutic approaches like cognitive behavioral therapy (CBT).
C) Incorrect - "Consciousness-raising" is not a recognized treatment intervention in this context.

It's important to focus on evidence-based therapeutic approaches for trauma-related symptoms, such as psychotherapy and support services.
D) Correct - Cognitive behavioral therapy (CBT) is Given the client's distressing thoughts and memories, CBT is a highly effective psychotherapy approach. It focuses on identifying and modifying negative thought patterns and behaviors associated with trauma. CBT can help the client develop healthier coping strategies.
E) Correct - Animal-assisted therapy involves interacting with trained animals to improve emotional well-being. Since the client expresses feeling unhappy and having difficulty coping, animal therapy can provide comfort, reduce stress, and promote a sense of companionship.
F) Incorrect - Electroconvulsive therapy (ECT) is a treatment primarily used for severe cases of depression or certain psychiatric conditions that are unresponsive to other treatments. It involves inducing controlled seizures to affect brain chemistry. ECT is not a first-line treatment for the client's distressing thoughts and memories following a traumatic event.

A. Dizziness reported after initial dose. B. A change in the sleep-wake cycle. C. Mild sedation. D. Somnambulism.

Correct Answer is D

Explanation

A) Incorrect- Dizziness is a common side effect of ramelteon and may occur initially as the body adjusts to the medication. While it's important to monitor and address dizziness, it may not require immediate reporting unless it's severe or persistent.

B) Incorrect- A change in the sleep-wake cycle is expected when using medications to treat sleep disorders. Ramelteon is designed to help regulate sleep patterns, so a change in the sleep-wake cycle is an anticipated effect.
C) Incorrect- Mild sedation is a common side effect of ramelteon and is usually well-tolerated.

It's important to educate the client about potential sedation effects and advise them not to engage in activities that require full alertness until they know how the medication affects them.
D) Correct- Somnambulism, also known as sleepwalking, is a potentially dangerous side effect that needs immediate attention from the healthcare provider. The client's safety is at risk due to the potential for injury during sleepwalking episodes.

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The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendation(s) should the nurse provide this client? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data What other treatments might be helpful for this client? Select all that apply.

Correct Answer is ["D","E"]

Explanation

A client who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing severe side effects since taking the drug. Which side effect should the nurse report to the healthcare provider?

Correct Answer is D

Explanation

The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client Indicates that the teaching was effective?

The home health nurse is assessing an older client who lives alone. The client reports being troubled by constipation. Which additional information should the nurse obtain to formulate a plan of care? (Select all that apply.)

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The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective?

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