The nurse is providing postoperative care for an adolescent who had an amputation of the left leg for osteosarcoma. The adolescent describes experiencing phantom limb pain. Which non pharmacological intervention should the nurse provide?

A Guide in moving the non affected limb to override the sensation being experienced.

B Reassure that this can be a normal postsurgical sensation.

C Affirm that a prosthetic with physical therapy will gradually improve the symptoms.

D Explain that the sensations of tingling and pain are not real.

Answer and Explanation

The Correct Answer is B

A. Guide in moving the non-affected limb to override the sensation being experienced.
Encouraging movement of the non-affected limb may not effectively address phantom limb pain and could potentially exacerbate discomfort or distress.

B. Reassure that this can be a normal postsurgical sensation.
Phantom limb pain is a common phenomenon after amputation surgeries. Providing reassurance that this sensation is normal can help alleviate anxiety and provide comfort to the adolescent.

C. Affirm that a prosthetic with physical therapy will gradually improve the symptoms.
While a prosthetic limb and physical therapy can help in the long term, they may not immediately address the phantom limb pain experienced in the early postoperative period.

D. Explain that the sensations of tingling and pain are not real.
Invalidating the adolescent's experience of phantom limb pain by suggesting that the sensations are not real may worsen distress and anxiety. It's essential to acknowledge the client's experience and provide supportive care.

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Correct Answer is D

Explanation

A. Begin abdominal girth measurements.
Abdominal girth measurements may be important for assessing fluid status in clients with liver disease and ascites, but in this case, the elevated polymorphonuclear leukocyte count indicates a possible infection, requiring immediate intervention.

B. Review serum protein levels.
While monitoring serum protein levels is important in clients with liver disease, the priority in this situation is to address the potential infection indicated by the elevated leukocyte count.

C. Assess neurological status.
Neurological assessment may be relevant in some cases, but it is not the priority in a client with suspected infection after a paracentesis.

D. Initiate antibiotic therapy.
Given the client's symptoms and the elevated polymorphonuclear leukocyte count in the ascitic fluid, indicating possible infection (spontaneous bacterial peritonitis), initiating antibiotic therapy is the priority action to address the infection and prevent further complications.

A. Listen attentively to the client's description of the event. B. Report the incident to the university's security department. C. Do not allow client to shower until all evidence is obtained. D. Determine the client's personal reaction to the reported rape.

Correct Answer is C

Explanation

A. Listen attentively to the client's description of the event. While important for providing emotional support, it is secondary to preserving forensic evidence.
B. Report the incident to the university's security department. This is necessary but not as immediately critical as preserving evidence.
C. Do not allow client to shower until all evidence is obtained. Preserving evidence is the highest priority in this situation to ensure a thorough forensic investigation and legal process.
D. Determine the client's personal reaction to the reported rape. Understanding the client's emotional state is important for providing support, but it should be done after ensuring that critical forensic evidence is collected.

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The nurse is providing postoperative care for an adolescent who had an amputation of the left leg for osteosarcoma. The adolescent describes experiencing phantom limb pain. Which non pharmacological intervention should the nurse provide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with decompensated liver disease who is experiencing fever, chills, and abdominal tenderness. Following a paracentesis, the nurse receives laboratory results. Exhibits After notifying the healthcare provider, which action should the nurse take next?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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