Which of the following interventions should the nurse include when caring for a client who is returning from surgery for an above-the-knee amputation?
Withhold medication for phantom limb pain as it isn't real pain.
Keep the residual limb elevated to achieve as close to 90-degree hip flexion as possible.
Continue using the limb prosthesis even if skin appears irritated.
Have the client lay prone for 30 minutes, 3-4 times a day.
The Correct Answer is D
A. Withholding medication for phantom limb pain is inappropriate. Phantom limb pain is a real phenomenon, and it should be managed with appropriate analgesics or other pain management strategies.
B. Keeping the residual limb elevated immediately after surgery is not recommended for prolonged periods as it can lead to contractures. The goal is to avoid excessive flexion at the hip and promote proper positioning.
C. Continuing to use the limb prosthesis when skin is irritated could worsen the irritation and cause skin breakdown. Proper skin care and regular monitoring are essential before using the prosthesis.
D. Laying prone for 30 minutes, 3-4 times a day is an appropriate intervention to prevent hip contractures and encourage proper alignment of the residual limb. This helps to maintain the flexibility of the hip joint and prepares the client for prosthetic fitting.
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Related Questions
Correct Answer is C
Explanation
A. The pain does not come from severed blood vessels in the residual stump. Phantom limb pain is not caused by the stump itself but rather by the brain’s perception of the missing limb.
B. Phantom limb pain is not psychosomatic. It is a real phenomenon where the brain continues to receive signals from nerves that were previously connected to the amputated limb.
C. Phantom limb pain is often treated with adjunct medications such as antiepileptics (e.g., gabapentin) and antidepressants (e.g., amitriptyline), which help modify the way the brain processes pain signals.
D. While opioid medications can be used for pain management, phantom limb pain often does not respond well to opioids. It typically requires a combination of other treatments, such as those mentioned in C.
Correct Answer is C
Explanation
A. Hyperactive reflexes are not typically associated with hypokalemia. In fact, hypokalemia can lead to hyporeflexia (decreased reflexes) due to the role of potassium in nerve function.
B. Extreme thirst is more commonly associated with hypernatremia or dehydration, not specifically with hypokalemia.
C. A flattened T-wave on an ECG is a classic sign of hypokalemia. Potassium plays a crucial role in maintaining the electrical activity of the heart, and low potassium levels can cause changes in the ECG, including a flattened T-wave.
D. Hyperactive bowel sounds are typically seen in conditions like gastroenteritis or early bowel obstruction, not directly related to hypokalemia. In fact, hypokalemia can sometimes lead to hypoactive or absent bowel sounds due to its effect on smooth muscle function.
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