Which nursing action(s) should the nurse include in the post-op plan of care for a client recovering from a below-the-knee amputation?
Administering pain medication as needed.
Encouraging the client to bear weight on the affected limb immediately after surgery.
Restricting the client's mobility and keeping the client on bed rest.
Applying a tight compression bandage on the residual limb.
The Correct Answer is A
Choice A reason:
Post-operative pain management is a critical aspect of care for a client recovering from a below-the-knee amputation. Administering pain medication as needed helps to manage pain effectively, which is essential for the client's comfort and recovery. Pain control is also important to facilitate participation in rehabilitation activities.
Choice B reason:
It is not advisable to encourage the client to bear weight on the affected limb immediately after surgery. The residual limb needs time to heal, and premature weight-bearing can lead to complications such as delayed healing or wound dehiscence.
Choice C reason:
While it is important to prevent complications such as deep vein thrombosis, complete restriction of mobility and keeping the client on bed rest is not recommended. Early mobilization, as part of a rehabilitation program, is essential for improving circulation, preventing muscle atrophy, and promoting overall recovery.
Choice D reason:
Applying a tight compression bandage on the residual limb is a common practice in the post-operative care of clients with amputations. The compression bandage helps to control swelling, shape the limb for a prosthesis, and prevent fluid accumulation. However, the bandage must be applied correctly to avoid impairing circulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Gas pains, while uncomfortable, are not typically a serious adverse effect of simvastatin and do not usually require immediate medical attention unless they are severe or persistent.
Choice B Reason:
Headaches are a common side effect of many medications, including simvastatin, and are not generally considered an emergency. However, if the headache is severe, persistent, or accompanied by other symptoms, it should be reported to a healthcare provider.
Choice C Reason:
Occasional constipation is another common side effect and is not usually a cause for immediate concern unless it becomes severe or chronic.
Choice D Reason:
Muscle weakness and pain, especially in the calves, can be a sign of a serious condition called rhabdomyolysis, which is a rare but serious adverse effect of statins like simvastatin. This condition involves the breakdown of muscle tissue and can lead to kidney damage. It should be reported to a healthcare provider immediately.
Correct Answer is B
Explanation
Choice A reason:
Allowing the client some time alone could be beneficial in certain situations where the client prefers solitude to process their emotions. However, in the context of intimate partner abuse, leaving the client alone when they are visibly distressed may not provide the immediate support and safety they need.
Choice B reason:
Remaining with the client is crucial in providing emotional support and ensuring their safety. Victims of intimate partner abuse often feel isolated and scared; having a compassionate presence can offer comfort and reassurance. The nurse's presence can also help in assessing the client's immediate needs and risks, and in facilitating access to further support and resources.
Choice C reason:
Making an audio recording without the client's consent could be a violation of privacy and trust. It is essential to respect the client's autonomy and confidentiality, especially in sensitive situations involving abuse. The priority should be to address the client's emotional state and safety, not to gather evidence.
Choice D reason:
Encouraging the client to write down their thoughts can be a therapeutic tool and may be suggested as part of ongoing therapy or coping strategies. However, it should not be the first action taken when the client is in acute distress. Immediate emotional support and safety planning are more pressing concerns.
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