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The nurse is providing postoperative care for an adolescent who underwent a left leg amputation due to osteosarcoma.

The adolescent reports experiencing phantom limb pain.

Which non-pharmacological intervention should the nurse provide?

A.

Reassure that this can be a normal post-surgical sensation.

B.

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

C.

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

D.

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

Answer and Explanation

The Correct Answer is A

Choice A rationale
Reassuring the adolescent that experiencing phantom limb pain can be a normal post-surgical sensation is the correct choice. Phantom limb pain is a common occurrence after amputation and can be very distressing for the patient. The nurse should validate the patient’s experience and provide reassurance. Non-pharmacological interventions such as mirror therapy, visualization, and other cognitive-behavioral strategies can also be helpful.

Choice B rationale
Guiding the patient in moving the non-affected limb to override the sensation being experienced is not the most appropriate intervention. While some therapies for phantom limb pain involve focusing on the remaining limb, this should be done under the guidance of a trained therapist.

Choice C rationale
Telling the patient that the sensations of tingling and pain are not real is not an appropriate intervention. Although the limb is no longer there, the pain that the patient is experiencing is very real. It is important to validate the patient’s experience and provide appropriate interventions.

Choice D rationale
Affirming that a prosthetic with physical therapy will gradually improve the symptoms is not the most appropriate intervention. While using a prosthetic and engaging in physical therapy can help with overall recovery and adaptation after amputation, they do not directly address phantom limb pain. The pain is a result of mixed signals from the brain and nerves, and it requires specific interventions.
 


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Related Questions

Correct Answer is B

Explanation

Choice A rationale
Monitoring leukocytes, neutrophils, and thyroxine is not the most crucial for a patient with end-stage renal disease (ESRD). While these lab values can provide information about the patient’s immune function and thyroid function, they do not directly relate to the patient’s renal function.
Choice B rationale
Monitoring serum potassium, calcium, and phosphorus levels is crucial for a patient with ESRD. These electrolytes are typically excreted by the kidneys, and their levels can become imbalanced in patients with ESRD. Imbalances can lead to serious complications, such as cardiac arrhythmias and bone disease.
Choice C rationale
Monitoring erythrocytes, hemoglobin, and hematocrit is important for a patient with ESRD, as these patients often develop anemia due to decreased erythropoietin production by the kidneys. However, these are not the only lab values that should be monitored in these patients.
Choice D rationale

Monitoring blood pressure, heart rate, and temperature is important for all patients, but these are not specific to patients with ESRD. Patients with ESRD are at risk for electrolyte imbalances, which can affect cardiac function, making monitoring of serum potassium, calcium, and phosphorus levels more crucial.

Correct Answer is C,A,B,D

Explanation

Choice C rationale

The first step in managing a patient with abdominal pain and distention is to complete a focused assessment. This will help the nurse determine the severity of the patient’s condition and guide subsequent interventions.

Choice A rationale

Elevating the head of the bed can help reduce the risk of aspiration, especially in a patient who has recently vomited. This is particularly important in this case as the patient’s vomit is dark brown, indicating possible upper gastrointestinal bleeding.

Choice B rationale

Sending the emesis sample to the lab is important for determining the cause of the patient’s symptoms. The lab can analyze the sample for the presence of blood or other abnormalities.

Choice D rationale

Offering PRN pain medication is important for patient comfort. However, it should be done after the assessment and initial interventions have been completed. The medication may mask symptoms that could provide important diagnostic information.

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