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Musculoskeletal Saunders NCLEX with
complete solution 2024
On a visit to the clinic, a client reports the onset of early symptoms of rheumatoid arthritis. The nurse should conduct a focused assessment for:
1. Limited motion of joints.
2. Deformed joints of the hands. 3.
Early morning stiffness.
- Rheumatoid nodules. - correct answer 3. Initially, most clients with early symptoms of rheumatoid arthritis complain of early morning stiffness or stiffness after sitting still for a while. Later symptoms of rheumatoid arthritis include limited joint range of motion; deformed joints, especially of the hand; and rheumatoid nodules.
- A client with rheumatoid arthritis states, "I can't do my household chores without becoming tired. My knees hurt whenever I walk." Which nursing diagnosis would be most appropriate?
- Activity intolerance related to fatigue and pain. 2. Self- care deficit related to increasing joint pain. 3. Ineffective coping related to chronic pain.
- Disturbed body image related to fatigue and joint pain. - correct answer 1. Based on the client's complaints, the most appropriate nursing diagnosis would be Activity intolerance related to fatigue and pain. Nursing interventions would focus on helping the client conserve energy and decrease episodes of fatigue. Although the client may develop a self-care deficit related to the activity intolerance and increasing joint pain, the client is voicing concerns about household chores and difficulty around the house and yard, not self-care issues. Over time, the client may develop ineffective coping or body image disturbance as the disorder becomes chronic with increasing pain and fatigue. Of the clients listed below, who is at risk for developing rheumatoid arthritis (RA)? Select all that apply.
1. Adults between the ages of 20 and 50 years.
2. Adults who have had an infectious disease with the Epstein-Barr virus. 3. Adults
that are of the male gender.
- Adults who possess the genetic link, specifically HLA-DR4. 5. Adults who also have osteoarthritis. - correct answer 1, 2, 4. Rheumatoid arthritis (RA) affects women three times more often than men, between the ages of 20 and 55 years. Research has determined that RA occurs in clients who have had infectious disease, such as the Epstein-Barr virus. The genetic link, specifically HLA-DR4, has been found in 65% of clients with RA. People with osteoarthritis are not necessarily at risk for developing rheumatoid arthritis.
A client is in the acute phase of rheumatoid arthritis. Which of the following should the nurse identify as lowest priority in the plan of care?
1. Relieving pain.
2. Preserving joint function.
3. Maintaining usual ways of accomplishing tasks. 4.
Preventing joint deformity. - correct answer 3. Maintaining usual ways of accomplishing tasks would be the lowest priority during the acute phase. Rather, the focus is on developing less stressful ways of accomplishing routine tasks. Pain relief is a high priority during the acute phase because pain is typically severe and interferes with the client's ability to function. Preserving joint function and preventing joint deformity are high priorities during the acute phase to promote an optimal level of functioning and reduce the risk of contractures. The nurse teaches a client about heat and cold treatments to manage arthritis pain. Which of the following client statements indicates that the client still has a knowledge deficit?
1. "I can use heat and cold as often as I want."
2. "With heat, I should apply it for no longer than 20 minutes at a time." 3. "Heat-
producing liniments can be used with other heat devices."
- "Ten to 15 minutes per application is the maximum time for cold applications." - correct answer 3. Heat-producing liniment can produce a burn if used with other heat devices that could intensify the heat reaction. Heat and cold can be used as often as the client desires. However, each application of heat should not exceed 20 minutes, and each application of cold should not exceed 10 to 15 minutes. Application for longer periods results in the opposite of the intended effect: vasoconstriction instead of vasodilation with heat, and vasodilation instead of vasoconstriction with cold. The client with rheumatoid arthritis tells the nurse, "I have a friend who took gold shots and had a wonderful response. Why didn't my physician let me try that?" Which of the following responses by the nurse would be most appropriate?
1. "It's the physician's prerogative to decide how to treat you. The physician has chosen what is best
for your situation."
2. "Tell me more about your friend's arthritic condition. Maybe I can answer that question
for you."
3. "That drug is used for cases that are worse than yours. It wouldn't help you, so don't worry about
it."
4. "Every person is different. What works for one client may not always be effective for another." -
correct answer 4. The nurse's most appropriate response is one that is therapeutic. The basic principle of therapeutic communication and a therapeutic relationship is honesty. Therefore, the nurse needs to explain truthfully that each client is different and that there are various forms of arthritis and arthritis treatment. To state that it is the physician's prerogative to decide how to treat the client implies that the client is not a member of his or her own health care team and is not a participant in his or her care. The statement also is defensive, which serves to block any further communication or questions from the client
Because some over-the-counter vitamin supplements contain folic acid, the client should avoid self- medication with vitamins while taking methotrexate, a folic acid antagonist. Because methotrexate is hepatotoxic, the client should avoid the intake of alcohol, which could increase the risk for hepatotoxicity. Methotrexate can cause bone marrow depression, placing the client at risk for infection. Therefore, meticulous mouth care is essential to minimize the risk of infection. Contraception should be used during methotrexate therapy and for 8 weeks after the therapy has been discontinued because of its effect on mitosis. Methotrexate is considered teratogenic. A 25-year-old client taking hydroxychloroquine (Plaquenil) for rheumatoid arthritis reports difficulty seeing out of her left eye. Correct interpretation of this assessment finding indicates which of the following?
- Development of a cataract. 2. Possible retinal degeneration. 3. Part of the disease process.
- A coincidental occurrence. - correct answer 2. Difficulty seeing out of one eye, when evaluated in conjunction with the client's medication therapy regimen, leads to the suspicion of possible retinal degeneration. The possibility of an irreversible retinal degeneration caused by deposits of hydroxychloroquine (Plaquenil) in the layers of the retina requires an ophthalmologic examination before therapy is begun and at 6-month intervals. Although cataracts may develop in young adults, they are less likely, and damage from the hydroxychloroquine is the most obvious at-risk factor. Eyesight is not affected by the disease process of rheumatoid arthritis. A client with rheumatoid arthritis tells the nurse, "I know it is important to exercise my joints so that I won't lose mobility, but my joints are so stiff and painful that exercising is difficult." Which of the following responses by the nurse would be most appropriate?
- "You are probably exercising too much. Decrease your exercise to every other day." 2. "Tell the physician about your symptoms. Maybe your analgesic medication can be increased."
3. "Stiffness and pain are part of the disease. Learn to cope by focusing on activities you enjoy."
4. "Take a warm tub bath or shower before exercising. This may help with your
discomfort." - correct answer 4. Superficial heat applications, such as tub baths, showers, and warm compresses, can be helpful in relieving pain and stiffness. Exercises can be performed more comfortably and more effectively after heat applications. The client with rheumatoid arthritis must balance rest with exercise every day, not every other day. Typically, large doses of analgesics, which can lead to hepatotoxic effects, are not necessary. Learning to cope with the pain by refocusing is inappropriate. Which of the following statements should the nurse include in the teaching session when preparing a client for arthrocentesis? Select all that apply.
- "A local anesthetic agent may be injected into the joint site for your comfort." 2. "A syringe and needle will be used to withdraw fluid from your joint."
3. "The procedure, although not painful, will provide immediate relief."
4. "We'll want you to keep your joint active after the procedure to increase blood flow." 5. "You will
need to wear a compression bandage for several days after the procedure."
- correct answer 1, 2, 5. An arthrocentesis is performed to aspirate excess synovial fluid, pus, or blood from a joint cavity to relieve pain or to diagnosis inflammatory diseases such as rheumatoid arthritis. A local agent may be used to decrease the pain of the needle insertion through the skin and into the joint cavity. Aspiration of the fluid into the syringe can be very painful because of the size and inflammation of the joint. Usually a steroid medication is injected locally to alleviate the inflammation; a compression bandage is applied to help decrease swelling; and the client is asked to rest the joint for up to 24 hours afterwards to help relieve the pain and promote rest to the inflamed joint. The client may experience pain during this time until the inflammation begins to resolve and swelling decreases. A client with osteoarthritis will undergo an arthrocentesis on his painful edematous knee. What should be included in the nursing plan of care? Select all that apply.
1. Explain the procedure.
2. Administer preoperative medication 1 hour before surgery.
3. Instruct the client to immobilize the knee for 2 days after the surgery. 4. Assess
the site for bleeding.
- Offer pain medication. - correct answer 1, 4, 5. To prepare a client for an arthrocentesis, the nurse should tell the client that a local anesthetic administered by the physician will decrease discomfort. There may be bleeding after the procedure, so the nurse should check the dressing. The client may experience pain. The nurse should offer pain medication and evaluate outcomes for pain relief. Because a local anesthetic is used, the client will not require preoperative medication. The client will rest the knee for 24 hours and then should begin range-of- motion and muscle strengthening exercises. A postmenopausal client is scheduled for a bone-density scan. To plan for the client's test, what should the nurse communicate to the client?
1. Request that the client remove all metal objects on the day of the scan.
2. Instruct the client to consume foods and beverages with a high content of calcium for 2 days
before the test.
3. Inform the client that she will need to ingest 600 mg of calcium gluconate by mouth for 2 weeks
before the test.
4. Tell the client that she should report any significant pain to her physician at least 2 days before
the test. - correct answer 1. Metal will interfere with the test. Metallic objects within the examination field, such as jewelry, earrings, and dental amalgams, may inhibit organ visualization and can produce unclear images. Ingesting foods and beverages days before the test will not affect bone mineral status. Short-term calcium gluconate intake will also not influence bone mineral status. The client may already have had chronic pain as a result of a bone fracture or from osteoporosis.
1. "I always wash my hands right after I apply the cream."
2. "After I apply the cream, I wrap my knee with an elastic bandage." 3. "I keep
the cream in the cabinet above the stove in the kitchen."
- "I also use the same cream when I get a cut or a burn." - correct answer 1. Capsaicin cream, which produces analgesia by preventing the reaccumulation of substance P in the peripheral sensory neurons, is made from the active ingredients of hot peppers. Therefore, clients should wash their hands immediately after applying capsaicin cream if they do not wear gloves, to avoid possible contact between the cream and mucous membranes. Clients are instructed to avoid wearing tight bandages over areas where capsaicin cream has been applied because swelling may occur from inflammation of the arthritis in the joint and lead to constriction on the peripheral neurovascular system. Capsaicin cream should be stored in areas between 59 ° F and 86 ° F (15 ° C and 30 ° C). The cabinet over the stove in the kitchen would be too warm. Capsaicin cream should not come in contact with irritated and broken skin, mucous membranes, or eyes. Therefore it should not be used on cuts or burns. At which of the following times should the nurse instruct the client to take ibuprofen (Motrin), prescribed for left hip pain secondary to osteoarthritis, to minimize gastric mucosal irritation?
1. At bedtime.
2. On arising.
3. Immediately after a meal.
4. On an empty stomach. - correct answer 3.
Drugs that cause gastric irritation, such as ibuprofen, are best taken after or with a meal, when stomach contents help minimize the local irritation. Taking the medication on an empty stomach at any time during the day will lead to gastric irritation. Taking the drug at bedtime with food may cause the client to gain weight, possibly aggravating the osteoarthritis. When the client arises, he is stiff from immobility and should use warmth and stretching until he gets food in his stomach. The client diagnosed with osteoarthritis states, "My friend takes steroid pills for her rheumatoid arthritis. Why don't I take steroids for my osteoarthritis?" Which of the following is the best explanation?
- Intra-articular corticosteroid injections are used to treat osteoarthritis. 2. Oral corticosteroids can be used in osteoarthritis.
3. A systemic effect is needed in osteoarthritis.
4. Rheumatoid arthritis and osteoarthritis are two similar diseases. - correct answer 1. Corticosteroids
are used for clients with osteoarthritis to obtain a local effect. Therefore, they are given only via intra- articular injection. Oral corticosteroids are avoided because they can cause an acceleration of osteoarthritis. Rheumatoid arthritis and osteoarthritis are two different diseases. After teaching a group of clients with osteoarthritis about using regular exercise, which of the following client statements indicates effective teaching?
- "Performing range-of-motion exercises will increase my joint mobility." 2.
"Exercise helps to drive synovial fluid through the cartilage."
4. Pinkness. - correct answer 1.
The nurse should suspect nerve damage if numbness is present. However, whether the damage is short-term and related to edema or long-term and related to permanent nerve damage would not be clear at this point. The nurse needs to continue to assess the client's neurovascular status, including pain, pallor, pulselessness, paresthesia, and paralysis (the five P's). Bleeding would suggest vascular damage or hemorrhage. Dislocation would suggest malalignment. Pink color would suggest adequate circulation to the area. Numbness would suggest neurologic damage. After surgery and insertion of a total joint prosthesis, a client develops severe sudden pain and an inability to move the extremity. The nurse correctly interprets these findings as indicating which of the following?
1. A developing infection.
2. Bleeding in the operative site. 3.
Joint dislocation.
- Glue seepage into soft tissue. - correct answer 3. The joint has dislocated when the client with a total joint prosthesis develops severe sudden pain and an inability to move the extremity. Clinical manifestations of an infection would include inflammation, redness, erythema, and possibly drainage and separation of the wound. Bleeding could be external (e.g., blood visible from the wound or on the dressing) or internal and manifested by signs of shock (e.g., pallor, coolness, hypotension, tachycardia). The seepage of glue into soft tissue would have occurred in the operating room, when the glue is still in the liquid form. The glue dries into the hard, fixed form before the wound is closed. A client who had a total hip replacement 2 days ago has developed an infection with a fever. The nursing diagnosis of fluid volume deficit related to diaphoresis is made. Which of the following is the most appropriate outcome? 1. The client drinks 2,000 mL of fluid per day.
- The client understands how to manage the incision. 3. The client's bed linens are changed as needed.
- The client's skin remains cool throughout hospitalization. - correct answer 1. An average adult requires approximately 1,100- 1,400 mL of fluids per day. In some instances, such as when a person has an increase in body temperature or has increased perspiration, additional water may be necessary. With an increase in body temperature, there is also an increase in insensible fluid loss. The increased loss of fluid causes an increased need for fluid replacement. If the loss is significant and/ or goes untreated, an individual's intake will not be balanced with output. Managing the incision, changing the bed linens, or keeping the client's skin cool are not outcomes indicative of resolution of a fluid volume deficit. After knee arthroplasty, the client has a sequential compression device (SCD). The nurse should do which of the following?
1. Elevate the sequential compression device (SCD) on two pillows.
2. Change the settings on the SCD to make the client more comfortable. 3. Stop the
SCD to remove dressings and bathe the leg.
3. For meals, elevate the head of the bed to 90 degrees. 4. Use a fracture bedpan when needed by
the client.
- When the client is in bed, prevent thromboembolism by encouraging the client to do toe-pointing exercises. - correct answer 2, 4, 5. Following total hip replacement, the client should use the overhead trapeze to assist with position changes. The head of the bed should not be elevated more than 45 degrees; any height greater than 45 degrees puts a strain on the hip joint and may cause dislocation. To use a fracture bedpan, instruct the client to flex the unoperated hip and knee to lift buttocks onto pan. Toe-pointing exercises stimulate circulation in the lower extremities to prevent the formation of thrombi and potential emboli. The prone position is avoided shortly after a total hip replacement. A client is to have a total hip replacement. The preoperative plan should include which of the following? Select all that apply.
- Administer antibiotics as prescribed to ensure therapeutic blood levels. 2. Apply leg compression device.
3. Request a trapeze be added to the bed.
4. Teach isometric exercises of quadriceps and gluteal muscles. 5.
Demonstrate crutch walking with a 3-point gait.
- Place Buck's traction on the bed. - correct answer 1, 3, 4. Administration of antibiotics as prescribed will aid in the acquisition of therapeutic blood levels during and immediately after surgery to prevent osteomyelitis. The nurse can request that a trapeze be added to the bed so the client can assist with lifting and turning. The nurse should also demonstrate and have the client practice isometric exercises (muscle setting) of quadriceps and gluteal muscles. The client will not use crutches after surgery; a physical therapy assistant will initially assist the client with walking by using a walker. The client will not use Buck's traction. The client will require anti- embolism stockings and use of a leg compression device to minimize the risk of thrombus formation and potential emboli; the leg compression device is applied during surgery and maintained per physician order. The nurse is teaching the client to administer enoxaparin (Lovenox) following a total hip arthroplasty? The nurse should instruct the client about which of the following? Select all that apply.
- Report promptly any difficulty breathing, rash, or itching. 2. Notify the health care provider of unusual bruising.
3. Avoid all aspirin-containing medications.
4. Wear or carry medical identification. 5. Expel the air bubble from the syringe before the
injection. 6. Remove needle immediately after medication is injected. - correct answer 1, 2, 3, 4. Client/ family teaching should include advising the client to report any symptoms of unusual bleeding or bruising, dizziness, itching, rash, fever, swelling, or difficulty breathing to healthcare provider immediately. Instruct the client not to take aspirin or nonsteroidal anti-inflammatory drugs without consulting health care provider while on therapy. A low-molecular weight heparin is considered to be a high-risk medication and the client should wear or carry medical identification. The air bubble should not be
expelled from the syringe because the bubble insures the client receives the full dose of the medication. The client should allow 5 seconds to pass before withdrawing the needle to prevent seepage of the medication out of the site. A client who had a total hip replacement 4 days ago is worried about dislocation of the prosthesis. The nurse should respond by saying which of the following?
1. "Don't worry. Your new hip is very strong."
2. "Use of a cushioned toilet seat helps to prevent dislocation."
3. "Activities that tend to cause adduction of the hip tend to cause dislocation, so try to avoid
them."
4. "Decreasing use of the abductor pillow will strengthen the muscles to prevent
dislocation." - correct answer 3. Dislocation precautions include: avoid extremes of internal rotation, adduction, and 90- degree flexion of affected hip for at least 4 to 6 weeks after the procedure. Use of an abduction pillow prevents adduction. Decreasing use of the abductor pillow does not strengthen the muscles to prevent dislocation. Informing a client to "not worry" is not therapeutic. A cushioned toilet seat does not prevent hip dislocation. The nurse is assessing a client who had a left hip replacement 36 hours ago. Which of the following indicates the prosthesis is dislocated? Select all that apply.
- The client reported a "popping" sensation in the hip. 2. The left leg is shorter than the right leg.
- The client has sharp pain in the groin. 4. The client cannot move his right leg. 5. The client - correct answer 1, 2, 3. Dislocation of a hip prosthesis may occur with positioning that exceeds the limits of the prosthesis. The nurse must recognize dislocation of the prosthesis. Signs of prosthesis dislocation include: acute groin pain in the affected hip, shortening of the affected leg, restricted ability or inability to move the affected leg, and reported "popping" sensation in the hip. Toe wiggling is not a test for potential hip dislocation. A client who has had a total hip replacement has a dislocated hip prosthesis. The nurse should first?
- Stabilize the leg with Buck's traction. 2. Apply an ice pack to the affected hip.
- Position the client toward the opposite side of the hip. 4. Notify the orthopedic surgeon. - correct answer 4. If a prosthesis becomes dislocated, the nurse should immediately notify the surgeon. This is done so the hip can be reduced and stabilized promptly to prevent nerve damage and to maintain circulation. After closed reduction, the hip may be stabilized with Buck's traction or a brace to prevent recurrent dislocation. If ordered by the surgeon, an ice pack may be applied post reduction to limit edema, although caution must be utilized due to potential muscle spasms. Some orthopedic surgeons may order the client be turned toward the side of the reduced hip but that is not the nurse's first response.
- Encourage the client to apply full weight-bearing. 2. Order a walker for the client.
- Place a straight-backed chair at the foot of the bed. 4. Apply a knee immobilizer. - correct answer 4. The knee is usually protected with a knee immobilizer (splint, cast, or brace) and is elevated when the client sits in a chair. Pre- and post-surgery, the physician prescribes weight-bearing limits and use of assistive devices for progressive ambulation. Positioning a straight-backed chair at the foot of the bed is not an action conducive for getting the client out of bed on the evening of surgery for a total knee replacement. When preparing a client for discharge from the hospital after a total knee replacement, the nurse should include which of the following information in the discharge plan? Select all that apply.
1. Report signs of infection to health care provider.
2. Keep the affected leg and foot on the floor when sitting in a chair. 3.
Remove anti-embolism stockings when sleeping.
4. The physical therapist will encourage progressive ambulation with use of assistive devices.
5. Change the dressing daily. - correct answer 1, 4.
After a total knee replacement, efforts are directed at preventing complications, such as thromboembolism, infection, limited range of motion, and peroneal nerve palsy. The nurse should instruct the client to report signs of infection, such as an increased temperature. To prevent edema, the affected leg must remain elevated when the client sits in a chair. After discharge, the client may undergo physical therapy on an outpatient basis per physician order. The client should leave the dressing in place until the follow- up visit with the surgeon. Following a total joint replacement, which of the following complications has the greatest likelihood of occurring?
- Deep vein thrombosis (DVT). 2. Polyuria.
3. Intussception of the bowel.
4. Wound evisceration. - correct answer 1.
Deep vein thrombosis is a complication of total joint replacement and may occur during hospitalization or develop later when the client is home. Clients who are obese or have previous history of a DVT or PE are at high risk. Immobility produces venous stasis, increasing the client's chance to develop a venous thromboembolism. Signs of a DVT include: unilateral calf tenderness, warmth, redness, and edema (increased calf circumference). Findings should be reported promptly to the physician for definitive evaluation and therapy. Polyuria may be indicative of diabetes mellitus. Intussusception of the bowel and wound evisceration tend to occur after abdominal surgeries. Which of the following should the nurse identify as the least likely factor contributing to a client's peripheral vascular disease?
- Uncontrolled diabetes mellitus for 15 years. 2. A 20-pack-year history of cigarette smoking.
3. Current age of 39 years.
4. A serum cholesterol concentration of 275 mg/ dL. - correct answer 3.
Typically, peripheral vascular disease is considered to be a disorder affecting older adults. Therefore, an age of 39 years would not be considered as a risk factor contributing to the development of peripheral vascular disease. Uncontrolled diabetes mellitus is considered a risk factor for peripheral vascular disease because of the macroangiopathic and microangiopathic changes that result from poor blood glucose control. Cigarette smoking is a known risk factor for peripheral vascular disease. Nicotine is a potent vasoconstrictor. Serum cholesterol levels greater than 200 mg/ dL are considered a risk factor for peripheral vascular disease. A client has severe arterial occlusive disease and gangrene of the left great toe. Which of the following findings is expected?
1. Edema around the ankle.
2. Loss of hair on the lower leg. 3.
Thin, soft toenails.
- Warmth in the foot. - correct answer 2. The client with severe arterial occlusive disease and gangrene of the left great toe would have lost the hair on the leg due to decreased circulation to the skin. Edema around the ankle and lower leg would indicate venous insufficiency of the lower extremity. Thin, soft toenails (i.e., not thickened and brittle) are a normal finding. Warmth in the foot indicates adequate circulation to the extremity. Typically, the foot would be cool to cold if a severe arterial occlusion were present. A client with absent peripheral pulses and pain at rest is scheduled for an arterial Doppler study of the affected extremity. When preparing the client for this test, the nurse should:
- Have the client sign a consent form for the procedure. 2. Administer a pretest sedative as appropriate.
3. Keep the client tobacco-free for 30 minutes before the test.
4. Wrap the client's affected foot with a blanket. - correct answer 3.
The client should be tobacco-free for 30 minutes before the test to avoid false readings related to the vasoconstrictive effects of smoking on the arteries. Because this test is noninvasive, the client does not need to sign a consent form. The client should receive an opioid analgesic, not a sedative, to control the pain as the blood pressure cuffs are inflated during the Doppler studies to determine the ankle-to-brachial pressure index. The client's ankle should not be covered with a blanket because the weight of the blanket on the ischemic foot will cause pain. A bed cradle should be used to keep even the weight of a sheet off the affected foot. The client with peripheral arterial disease says, "I've really tried to manage my condition well." Which of the following should the nurse determine as appropriate for this client? 1. Resting with the legs elevated above the level of the heart.
- Walking slowly but steadily for 30 minutes twice a day. 3. Minimizing activity as much and as often as possible.
Slow, steady walking is a recommended activity for the client with peripheral arterial disease because it stimulates the development of collateral circulation needed to ensure adequate tissue oxygenation. The client with peripheral arterial disease should not minimize activity. Activity is necessary to foster the development of collateral circulation. Elevating the legs above the heart is an appropriate strategy for reducing venous congestion. Wearing antiembolism stockings promotes the return of venous circulation, which is important for clients with venous insufficiency. However, their use in clients with peripheral arterial disease may cause the disease to worsen. Which of the following should the nurse include in the teaching plan for a client with arterial insufficiency to the feet that is being managed conservatively?
1. Daily lubrication of the feet.
2. Soaking the feet in warm water. 3.
Applying antiembolism stockings.
- Wearing firm, supportive leather shoes. - correct answer 1. Daily lubrication, inspection, cleaning, and patting dry of the feet should be performed to prevent cracking of the skin and possible infection. Soaking the feet in warm water should be avoided because soaking can lead to maceration and subsequent skin breakdown. Additionally, the client with arterial insufficiency typically experiences sensory changes, so the client may be unable to detect water that is too warm, thus placing the client at risk for burns. Antiembolism stockings, appropriate for clients with venous insufficiency, are inappropriate for clients with arterial insufficiency and could lead to a worsening of the condition. Footwear should be roomy, soft, and protective and allow air to circulate. Therefore, firm, supportive leather shoes would be inappropriate. A client says, "I hate the idea of being an invalid after they cut off my leg." Which of the following would be the nurse's most therapeutic response?
- "At least you will still have one good leg to use." 2. "Tell me more about how you're feeling."
3. "Let's finish the preoperative teaching."
4. "You're lucky to have a wife to care for you." - correct answer 2.
Encouraging the client who will be undergoing amputation to verbalize his feelings is the most therapeutic response. Asking the client to tell more about how he is feeling helps to elicit information, providing insight into his view of the situation and also providing the nurse with ideas to help him cope. The nurse should avoid value-laden responses, such as, "At least you will still have one good leg to use," that may make the client feel guilty or hostile, thereby blocking further communication. Furthermore, stating that the client still has one good leg ignores his expressed concerns. The client has verbalized feelings of helplessness by using the term "invalid." The nurse needs to focus on this concern and not try to complete the teaching first before discussing what is on the client's mind. The client's needs, not the nurse's needs, must be met first. It is inappropriate for the nurse to assume to know the relationship between the client and his wife or the roles they now must assume as dependent client and caregiver. Additionally, the response about the client's wife caring for him may reinforce the client's feelings of helplessness as an invalid.
The client asks the nurse, "Why can't the physician tell me exactly how much of my leg he's going to take off? Don't you think I should know that?" On which of the following should the nurse base the response?
- The need to remove as much of the leg as possible. 2. The adequacy of the blood supply to the tissues.
3. The ease with which a prosthesis can be fitted.
4. The client's ability to walk with a prosthesis. - correct answer 2.
The level of amputation often cannot be accurately determined until during surgery, when the surgeon can directly assess the adequacy of the circulation of the residual limb. From a moral, ethical, and legal viewpoint, the surgeon attempts to remove as little of the leg as possible. Although a longer residual limb facilitates prosthesis fitting, unless the stump is receiving a good blood supply the prosthesis will not function properly because tissue necrosis will occur. Although the client's ability to walk with a prosthesis is important, it is not a determining factor in the decision about the level of amputation required. Blood supply to the tissue is the primary determinant. A client who has had an above-the-knee amputation develops a dime-sized bright red spot on the dressing after 45 minutes in the postanesthesia recovery unit. The nurse should:
1. Elevate the stump.
2. Reinforce the dressing. 3.
Call the surgeon.
- Draw a mark around the site. - correct answer 4. The priority action is to draw a mark around the site of bleeding to determine the rate of bleeding. Once the area is marked, the nurse can determine whether the bleeding is increasing or decreasing by the size of the area marked. Because the spot is bright red, the bleeding is most likely arterial in origin. Once the rate and source of bleeding are identified, the surgeon should be notified. The stump is not elevated because adhesions may occur, interfering with the ability to fit a prosthesis. The dressing would be reinforced if the bleeding is determined to be of venous origin, characterized by slow oozing of darker blood that ceases with the application of a pressure dressing. Typically, operative dressings are not changed for 24 hours. Therefore, the dressing is reinforced to prevent organisms from penetrating through the blood-soaked areas of the initial postoperative dressing. A client in the postanesthesia care unit with a left below-the-knee amputation has pain in her left big toe. Which of the following should the nurse do first?
- Tell the client it is impossible to feel the pain. 2. Show the client that the toes are not there.
3. Explain to the client that her pain is real.
4. Give the client the prescribed opioid analgesic. - correct answer 4.
The nurse's first action should be to administer the prescribed opioid analgesic to the client, because this phenomenon is phantom sensation and interventions should be provided to relieve it. Pain relief is the priority. Phantom sensation is a real sensation. It is incorrect and inappropriate to tell a client that it is impossible to feel the pain.
