a client recently had an above the knee amputation and complains of pain distal to the amputation what type of pain is the client experiencing

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. A client recently had an above the knee amputation and complains of pain distal to the amputation. What type of pain is the client experiencing?

A. Nociceptive
B. Neuropathic
C. Visceral
D. Cutaneous

Correct answer: A

Rationale:

2. What is the priority nursing diagnosis for a client with immobility?

A. Constipation related to immobility
B. Ineffective breathing pattern related to inability to breathe deeply in a supine position
C. Risk for impaired skin integrity as evidenced by pressure over bony prominences
D. Risk for disuse syndrome as evidenced by immobility

Correct answer: C

Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.

3. What is correct about a nursing diagnosis?

A. It is a human response to disease, injury, or other stressors.
B. It remains constant as long as the disease is present.
C. It is a way to identify pathology.
D. It is a disease, illness, or injury.

Correct answer: A

Rationale: A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems or life processes. Choice A is correct because it identifies nursing diagnosis as related to human responses to health conditions or life processes. Choice B is incorrect because nursing diagnoses can change as the patient's condition changes. Choice C is incorrect because a nursing diagnosis is about responses, not just identifying pathology. Choice D is incorrect because a nursing diagnosis is not the same as a disease, illness, or injury; it is a statement about the patient's response to these conditions.

4. Which nonpharmacological intervention does not help reduce edema?

A. Heat therapy
B. Passive range of motion (PROM)
C. Elevation of the extremity
D. Cold therapy

Correct answer: A

Rationale: The correct answer is A: Heat therapy. Heat therapy can vasodilate blood vessels, increasing blood flow to the area and potentially exacerbating edema. Passive range of motion (PROM), elevation of the extremity, and cold therapy are all beneficial interventions for reducing edema. PROM helps with circulation, elevation assists in reducing fluid accumulation, and cold therapy can help constrict blood vessels and decrease swelling.

5. Death of bone tissue can occur when the blood supply to the bone is disrupted. What is this complication called?

A. Reflex sympathetic dystrophy
B. Avascular necrosis
C. Delayed union
D. Complex regional pain syndrome

Correct answer: B

Rationale: The correct answer is B, avascular necrosis. Avascular necrosis is the condition where bone tissue dies due to the disruption of blood supply to the bone. Reflex sympathetic dystrophy (Choice A) is a chronic pain condition, delayed union (Choice C) refers to a delayed healing of a fracture, and complex regional pain syndrome (Choice D) is a chronic pain condition typically affecting an arm or leg.