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 B

Explanation

A. An increase in breath sounds may suggest improved airflow, but it does not necessarily indicate effective mobilization of secretions.
B. Absence of fine crackles indicates that there are no longer small airway secretions or fluid in the lungs, suggesting that the chest physiotherapy was effective in mobilizing secretions.
C. While the absence of coarse crackles is also a positive finding, fine crackles specifically indicate fluid or secretions in the small airways, making their absence a more direct indicator of the effectiveness of chest physiotherapy.

D. An increase in respiratory rate may indicate respiratory distress or worsening of the condition, rather than effectiveness of the chest physiotherapy in mobilizing secretions.

A. Clamp the chest tube immediately with a plastic clamp. B. Apply an occlusive dressing over the chest tube site. C. Ensure the chest tubing is not kinked or hanging low. D. Reinforce the chest tube connection to the container with tape.

Correct Answer is C

Explanation

A. Clamp the chest tube immediately with a plastic clamp. Clamping the chest tube can lead to tension pneumothorax, which is a life-threatening complication. It should never be done unless specifically instructed by a healthcare provider.
B. Apply an occlusive dressing over the chest tube site. This action is not indicated in this situation and could interfere with drainage.
C. Ensure the chest tubing is not kinked or hanging low. This is the correct intervention as a kinked or dependent chest tube can impede drainage, leading to respiratory distress.
D. Reinforce the chest tube connection to the container with tape. While ensuring the chest tube connection is secure is important, it is not the priority in this situation where the client is experiencing sudden shortness of breath.

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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

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