PT 2

45問 • 1年前

問題一覧

Which goal is an appropriate outcome for a patient with feelings of anxiety related to a perceived threat of disability?

Anxiety is relieved; the patient verbalizes concern related to disability.

Which potential complication is the greatest danger in the early postoperative period after an amputation?

hemorrhage

A nurse is caring for a patient who has undergone replantation of a body part. Which physical issue might the saliva of leeches be used to treat in this patient?

venous congestion

A patient who amputated his thumb in a lawnmower accident hands the emergency department nurse his thumb in a glass jar. Which action is the best for the nurse to implement?

Wrap the thumb in a cloth saturated with normal saline and place it in a baggie.

A patient who has a below-the-elbow prosthesis shows the home health care nurse the residual limb, which is red, edematous, and warm to touch. Which action should the nurse instruct this patient to do?

Leave the prosthesis off and notify physician.

A child comes to the school nurse with his index finger partially amputated and hanging by a shred of skin and muscle. Which action is the best for the nurse to implement?

Wrap the hand and finger securely and place it on an ice water-filled plastic bag.

Which nursing action should be implemented in the postoperative care for a patient with replantation of the right thumb?

Elevating the hand but keeping it below the level of the heart

A nurse is caring for a patient with a recent below-the-knee amputation. Which action should the nurse recommend to this patient to prevent the loss of calcium and protein?

Ambulate 30 minutes a day.

Which signs are late indicators of hemorrhage in the postoperative period after an amputation?

Cyanosis and hypotension

Which outcome is measured by the following goal statement: "The patient will verbalize an understanding of microvascular precautions"?

Patient knowledge of therapeutic measures

Which postoperative observation must be reported to the physician immediately?

bright red bleeding

A home health care nurse suspects a neuroma in a patient who had an above-the-knee amputation 1 month earlier. Which complaint by the patient led the nurse to suspect a neuroma?

Sharp severe pain in the residual limb

Which action should a nurse implement to diminish swelling of the residual limb in the postoperative period after an above-the-knee amputation?

Elevate the foot of the bed on blocks

Which major situational occurrences might lead to amputations? (Select all that apply.)

trauma, disease, tumors, congenital defects

Which purpose relates to a closed amputation? (Select all that apply.)

Prepare a weight-bearing limb., Cover the stump with tissue and muscle

Which information should a nurse modify in a teaching plan for an older adult who has had an above-the-knee amputation? (Select all that apply.)

Offer smaller units of information at a time., Increase time for learning., Clarify the reality of phantom pain., Include frequent repetition.

A nurse clarifies that the precise term for the patient's amputation, which will be through the knee joint, is called _____

disarticulation

An amputation of a gangrenous limb that is left open for 10 days before closure is classified as a staged or ______amputation

guillotine

To reduce the possibility of hip contractures in a patient with an above-the-knee amputation, a nurse periodically places the patient in a(n)____position

prone

Preoperative exercises for a patient undergoing a lower-extremity amputation include training _____.

upper body

What should a nurse consider when selecting possible nursing diagnoses for a 32-year-old patient who is in anticipatory grieving for an upcoming bilateral above-the-knee amputation? (Select all that apply.)

Anxiety, related to knowledge deficit of procedure, Disturbed body image, related to loss of body part, Sexual dysfunction, related to perceived disfigurement, Disturbed self-image, related to loss of independence

A nurse clarifies that the precise term for the patient's amputation, which will be through the knee joint, is called_____

disarticulation

An amputation of a gangrenous limb that is left open for 10 days before closure is classified as a(n)____amputation

staged guillotine

Which information will the nurse teach seniors at a community recreation center about ways to prevent fractures?

Buy shoes that provide good support and are comfortable to wear.

A factory line worker has repetitive strain syndrome in the left elbow. The nurse will plan to teach the patient about

modifying arm movements.

The occupational health nurse will teach the patient whose job involves many hours of typing to

obtain a keyboard pad to support the wrist.

Which discharge instruction will the emergency department nurse include for a patient with a sprained ankle?

Use pillows to elevate the ankle above the heart.

A tennis player has an arthroscopic repair of a rotator cuff injury performed in same-day surgery. When the nurse plans postoperative teaching for the patient, which information will be included?

"You will begin work with a physical therapist tomorrow."

The nurse will instruct the patient with a fractured left radius that the cast will need to remain in place

for at least 3 weeks.

A patient with a fracture of the left femoral neck has Buck's traction in place while waiting for surgery. To assess for pressure areas on the patient's back and sacral area and to provide skin care, the nurse should

have the patient lift the buttocks slightly by using a trapeze over the bed.

Which nursing intervention will be included in the plan of care after a patient with a right femur fracture has a hip spica cast applied?

Ask the patient about abdominal discomfort.

A patient has a long-arm plaster cast applied for fracture immobilization. Until the cast has completely dried, the nurse should

avoid handling the cast using fingertips.

Which statement by the patient indicates a good understanding of the nurse's teaching about a new short-arm synthetic cast?

"I will apply an ice pack to the cast over the fracture site off and on for 24 hours."

A patient who is to have no weight bearing on the left leg is learning to walk using crutches. Which observation by the nurse indicates the patient can safely ambulate independently?

The patient advances the left leg and both crutches together and then advances the right leg.

A patient who has had open reduction and internal fixation (ORIF) of left lower leg fractures continues to complain of severe pain in the leg 15 minutes after receiving the prescribed IV morphine. Pulses are faintly palpable and the foot is cool to the touch. Which action should the nurse take next?

Notify the health care provider.

A patient with a complex pelvic fracture from a motor vehicle crash is on bed rest. Which nursing assessment finding indicates a potential complication of the fracture?

Abdomen is distended and bowel sounds are absent.

Which action will the nurse take in order to evaluate the effectiveness of Buck's traction for a patient who has an intracapsular fracture of the right femur?

Assess for hip pain.

A patient with a right lower leg fracture will be discharged home with an external fixation device in place. Which information will the nurse teach?

"Check and clean the pin insertion sites daily."

A patient who has had open reduction and internal fixation (ORIF) of a hip fracture tells the nurse he is ready to get out of bed for the first time. Which action should the nurse take?

Check the patient's prescribed weight-bearing status.

The nurse's discharge teaching for a patient who has had a repair of a fractured mandible will include information about

how and when to cut the immobilizing wires.

After the health care provider recommends amputation for a patient who has nonhealing ischemic foot ulcers, the patient tells the nurse that he would rather die than have an amputation. Which response by the nurse is best?

"Tell me what you know about your options for treatment."

The day after a having a right below-the-knee amputation, a patient complains of pain in the missing right foot. Which action is most important for the nurse to take?

Administer prescribed analgesics.

Which statement by a patient who has had an above-the-knee amputation indicates the nurse's discharge teaching has been effective?

"I should lie flat on my abdomen for 30 minutes 3 or 4 times a day."

The nurse is caring for a patient who is to be discharged from the hospital 4 days after insertion of a femoral head prosthesis using a posterior approach. Which statement by the patient indicates a need for additional instruction?

"I can sleep in any position that is comfortable for me."

Which action will the nurse include in the plan of care for a patient who had a cemented right total knee arthroplasty?

Start progressive knee exercises to obtain 90-degree flexion.

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