Nokea
A client with a below-the-knee amputation is experiencing phantom limb pain. Which action by the nurse would be most effective in relieving the pain?
- A. Acknowledging the presence of the pain
- B. Elevating the stump on a pillow
- C. Applying a transcutaneous nerve stimulator unit (TENS)
- D. Rewrapping the stump
Correct Answer: C
Rationale: Applying a TENS unit can help relieve phantom limb pain by stimulating nerves and reducing pain signals. Acknowledging the pain is supportive but does not directly relieve it. Elevating the stump may help with swelling but not specifically phantom pain. Rewrapping the stump may provide comfort but is less effective than TENS for pain relief.
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The nurse is screening clients for those at risk for developing a pressure injury. At highest risk for developing a pressure injury is the client
- A. who had an open cholecystectomy and has a closed-wound drainage device
- B. who has a long leg cast and a decreased serum albumin level
- C. with dementia, peripheral artery disease, and constipation
- D. with quadriplegia, moist skin, and an elevated temperature
Correct Answer: D
Rationale: Clients with quadriplegia are at high risk due to immobility, which impairs circulation and increases pressure on skin. Moist skin increases the risk of skin breakdown, and elevated temperature may indicate infection or inflammation, further increasing risk.
A nurse is reinforcing appropriate interventions with the parent of an infant who had a febrile seizure. Which instruction is appropriate to review?
- A. Give acetaminophen or ibuprofen every 6-8 hours to control fever.
- B. Give the infant frequent tepid sponge baths to control the fever.
- C. If the infant develops another seizure, wait 15 minutes to see if it subsides.
- D. Place ice bags under the arms and around the neck to control fever.
Correct Answer: A
Rationale: Administering acetaminophen or ibuprofen every 6-8 hours helps control fever, reducing the risk of recurrent febrile seizures in infants.
The nurse is caring for a 4-year-old who was hospitalized with influenza. Which nursing action would be most effective to maintain psychosocial integrity?
- A. Encouraging use of puzzles for play
- B. Offering the child stacking blocks for diversion
- C. Providing crayons to draw noses on facemasks
- D. Suggesting that playmates visit the child
Correct Answer: C
Rationale: Drawing on facemasks is an age-appropriate, creative activity that promotes self-expression and reduces fear associated with medical equipment, supporting psychosocial integrity.
The nurse is conducting a home visit to assess an elderly client with advanced heart failure who lives alone. When the nurse asks about sodium intake, the client becomes angry and says, 'I'm so tired of people telling me what to do! I'm going to eat what I want, so leave me alone!' Which of the following is the most appropriate response by the nurse?
- A. I can tell that you want me to go, so I will call in a few days to see how you are doing.
- B. I know you are frustrated with losing control of your life.
- C. It sounds like you are angry. Tell me what's bothering you.
- D. Okay. I'll just check your blood pressure and then go.
Correct Answer: C
Rationale: Acknowledging the client's anger and inviting them to express their feelings promotes therapeutic communication, helping to de-escalate the situation and address underlying concerns.
An older adult is seen in clinic. During the assessment process, all of the following are expressed or noted. Which is of most immediate concern to the nurse?
- A. The client's daughter says that the client has become increasingly forgetful.
- B. The client has a productive cough.
- C. The client ambulates slowly.
- D. The client says, 'My arms aren't long enough for me to read the paper.'
Correct Answer: B
Rationale: A productive cough suggests a respiratory infection, potentially serious in an older adult, requiring immediate evaluation. Forgetfulness, slow ambulation, or presbyopia are less urgent.