What is the major focus for care today for a patient who is 1 day post-operative after a left below-the-knee amputation?

Correct Answer: B

Rationale: The correct answer is B) To monitor for signs of sufficient tissue perfusion. After a below-the-knee amputation, monitoring tissue perfusion is crucial to ensure that the residual limb is receiving adequate blood flow. Insufficient perfusion can lead to complications such as delayed wound healing, infection, and tissue necrosis. By closely monitoring perfusion, healthcare providers can intervene promptly if any issues arise, thus promoting optimal healing and recovery for the patient. Option A) To attain pain control for phantom pain, while important, is not the major focus immediately post-operatively. Phantom pain may develop later on and can be managed with various strategies, but it is not the primary concern in the immediate post-operative period. Option C) To assist the patient to ambulate as soon as possible is not typically recommended one day after surgery. The priority is to ensure adequate healing and recovery before initiating ambulation to prevent complications. Option D) To elevate the residual limb when the patient is supine is a good practice to promote venous return and reduce swelling, but it is not the major focus in this scenario compared to monitoring tissue perfusion for signs of complications. In an educational context, understanding the importance of monitoring tissue perfusion post-amputation is crucial for providing safe and effective care to patients undergoing such procedures. This knowledge helps healthcare providers prioritize interventions and assessments to promote positive outcomes and prevent complications in the early post-operative period.

Correct Answer: A

Rationale: The correct answer is A) An IV line is inserted to provide access to a vein. This intervention is crucial because shock can occur as a complication of spinal cord injury due to neurogenic shock, which can lead to inadequate perfusion and oxygenation of tissues. Establishing IV access allows for the administration of fluids and medications to stabilize the client's condition and prevent further complications. Option B) Head and back immobilization with a cervical collar and back support is not directly related to managing shock in a client with spinal cord injury. While immobilization is important for spinal cord injury, it does not address the immediate need to manage shock. Option C) Traction with weights and pulleys is a treatment for spinal cord injuries to stabilize and align the spine, but it is not a precautionary measure for managing shock. Option D) The use of a turning frame is not indicated for managing shock in a client with spinal cord injury. Turning frames are typically used for repositioning and preventing pressure ulcers, not for addressing shock. In an educational context, understanding the rationale behind each nursing intervention is crucial for providing safe and effective care to clients with spinal cord injuries. Nurses must prioritize interventions that address the client's immediate physiological needs, such as managing shock, to ensure positive outcomes for their patients.

Correct Answer: D

Rationale: The correct answer to the question is option D, which states, "Be sure to take fluids frequently." This is the most appropriate advice for a client with a neurological deficit related to nutrition and diet for several reasons. Neurological deficits can affect swallowing function, leading to an increased risk of dehydration and aspiration. Encouraging the client to take fluids frequently helps maintain hydration, aids in swallowing, and prevents complications such as aspiration pneumonia. Option A, eating two large meals instead of frequent small meals, is incorrect because it can overload the digestive system, especially for individuals with neurological deficits that may have difficulty with digestion and absorption. Consuming smaller, more frequent meals is generally recommended for better nutrient absorption and energy distribution throughout the day. Option B, consuming a diet low in fiber, is also incorrect. Fiber is essential for digestive health and regular bowel movements. A diet low in fiber can lead to constipation, which can be exacerbated in individuals with neurological deficits who may already have gastrointestinal issues. Option C, chewing foods quickly, is incorrect as well. Clients with neurological deficits may have difficulty with chewing and swallowing, which can increase the risk of choking and aspiration. Chewing food thoroughly and slowly is important to prevent these risks and aid in digestion. In an educational context, it is crucial for nurses to provide tailored nutrition and diet advice to clients with neurological deficits to promote optimal health and prevent complications. Understanding the specific needs and challenges faced by these individuals is essential in developing appropriate dietary recommendations that support their overall well-being. Encouraging frequent fluid intake is a simple yet effective strategy to address hydration and swallowing issues commonly seen in this population.

Correct Answer: C

Rationale: In managing a patient with delirium, it is essential to prioritize the identification and treatment of underlying causes whenever possible. This is the correct answer (Option C) because delirium is often a symptom of an underlying medical issue such as infection, medication side effects, or metabolic disturbances. By addressing the root cause, the delirium can be effectively managed or resolved. Option A, the use of restraints, is inappropriate as it can lead to physical and psychological harm, and should only be considered as a last resort for safety reasons. Option B, the use of short-acting benzodiazepines, can worsen delirium by exacerbating confusion and sedation. Option D, administering high doses of antipsychotic drugs, is not recommended as it can increase the risk of adverse effects in elderly patients and those with underlying neurological conditions. In an educational context, understanding the management of delirium is crucial for healthcare professionals, especially those preparing for exams like the NCLEX. By emphasizing the importance of identifying and addressing underlying causes, students can provide safe and effective care for patients experiencing delirium, promoting better outcomes and quality of life.

Correct Answer: C

Rationale: The correct answer is C: Resolution of spinal shock is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder. This is the most appropriate answer because spinal shock is a temporary condition that occurs immediately after a spinal cord injury and is characterized by a loss of reflexes, flaccid paralysis, and absence of sensation below the level of injury. As the spinal shock resolves, the signs mentioned in option C begin to appear, indicating the return of reflex activity. Option A is incorrect because rehabilitation measures can actually begin during spinal shock to prevent complications and promote optimal recovery. Option B is incorrect because while continuous monitoring for hypotension, tachycardia, and hypoxemia is important in spinal cord injury patients, it is not specific to spinal shock resolution. Option D is incorrect because autonomic functions can be affected in spinal shock, leading to issues such as hypotension and bradycardia. In an educational context, understanding the progression of spinal shock and its resolution is crucial for nurses caring for patients with spinal cord injuries. Recognizing the signs of spinal shock resolution helps in planning appropriate care and interventions to support the patient's recovery and prevent complications. It is essential for nurses to be knowledgeable about neurological assessments, spinal cord injury management, and the implications of spinal shock to provide effective and evidence-based care.