Nokea
A male client had a right below-the-knee amputation 4 days ago. His incision is healing well. He has gotten out of bed several times and sat at the side of the bed. Each time after returning to bed, he has experienced pain as if it were located in his right foot. Which nursing measure indicates the nurse has a thorough understanding of phantom pain and its management?
- A. Phantom pain is entirely in the client's mind. The client should be instructed that the pain is psychological and should not be treated.
- B. The basis for phantom pain may occur because the nerves still carry pain sensation to the brain even though the limb has been amputated. The pain is real, intense, and should be treated.
- C. The cause of phantom pain is unknown. The nurse should provide the client with support, promote sleep, and handle the injured limb smoothly and gently.
- D. Phantom pain is caused by trauma, spasms, and edema at the incisional site. It will decrease when postoperative edema decreases. It should be treated with nonnarcotic medication whenever possible.
Correct Answer: B
Rationale: This statement is entirely false. Phantom pain may be caused by nerves continuing to carry sensation to the brain even though the limb is removed. It is real, intense, and should be treated as ordinary pain would. Although the cause of phantom pain is still unknown, these measures may promote the relief of any type of pain, not just phantom pain. Phantom pain is not caused by trauma, spasms, and edema and will not be relieved by decreasing edema.
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A client with severe PIH receiving MgSO4 is placed in a quiet, darkened room. The nurse bases this action on the following understanding:
- A. The client is restless.
- B. The elevated blood pressure causes photophobia.
- C. Noise or bright lights may precipitate a convulsion.
- D. External stimuli are annoying to the client with PIH.
Correct Answer: C
Rationale: The client may be anxious and hyperresponsive to stimuli but not necessarily restless. This is not a physiological response to an elevated blood pressure in PIH. The nurse must know the nursing measures that decrease the potential for convulsions. A quiet, darkened room decreases stimuli and promotes rest. External stimuli might induce a convulsion but are not annoying to the client with PIH.
Which finding is expected in the normal newborn?
- A. Epstein pearls
- B. Moro reflex
- C. Swan neck deformity
- D. Cracked pot sound
Correct Answer: B
Rationale: The Moro reflex, a startle response to sudden movement, is a normal finding in newborns, present until about 3-6 months. Epstein pearls are benign but not universal, and the others are abnormal.
The nurse who is caring for a client with cancer notes a WBC of 500/mm3 on the laboratory results. Which intervention would be most appropriate to include in the client's plan of care?
- A. Assess temperature every four hours because of risk for hypothermia.
- B. Instruct the client to avoid large crowds and people who are sick.
- C. Instruct in the use of a soft toothbrush.
- D. Assess for signs of bleeding.
Correct Answer: B
Rationale: A WBC of 500/mm3 indicates severe neutropenia, increasing infection risk. Avoiding crowds and sick people (B) is critical. Hypothermia (A) is not a primary concern, soft toothbrush (C) prevents bleeding, and bleeding (D) is for thrombocytopenia.
The physician has ordered a paracentesis for a client with severe abdominal ascites. Before the procedure, the nurse should:
- A. Provide the client with a urinal
- B. Prep the area by shaving the abdomen
- C. Encourage the client to drink extra fluids
- D. Request an ultrasound of the abdomen
Correct Answer: A
Rationale: Providing a urinal ensures the bladder is empty, reducing the risk of bladder puncture during paracentesis, a priority before the procedure.
Which term describes the play activity of the preschool aged child?
- A. Cooperative
- B. Associative
- C. Parallel
- D. Solitary
Correct Answer: B
Rationale: Preschool-aged children (3–5 years) typically engage in associative play, where they play together with shared activities but without formal rules or organization. Cooperative play develops later, parallel play is common in toddlers, and solitary play is seen in younger children.