A client asks a nurse how long a heat application should be left in place. Which response should the nurse make?
“Maximum benefits occur within the first five minutes.”.
“Therapeutic heat effects occur within 20 to 30 minutes.”.
“The heat should be left in place for at least one hour to be effective.”.
“Heat can be left in place for as long as 12 hours without harmful effects.”.
The Correct Answer is B
Heat application increases blood flow and reduces muscle spasms, which can help relieve pain and promote healing. However, heat should not be applied for longer than 30 minutes at a time, as it can cause tissue damage and inflammation.
Choice A is wrong because maximum benefits do not occur within the first five minutes.
It takes time for heat to penetrate the tissues and cause vasodilation.
Choice C is wrong because the heat should not be left in place for at least one hour to be effective.
This can lead to burns, increased edema, and decreased blood flow.
Choice D is wrong because heat can not be left in place for as long as 12 hours without harmful effects.
This can cause severe tissue damage, infection, and necrosis.
Normal ranges for heat application are between 104°F and 113°F (40°C and 45°C).
The temperature should be checked frequently and adjusted according to the patient’s comfort and tolerance.
The skin should also be inspected for signs of erythema, blisters, or burns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The client practices meditation for 20 minutes once a day. This is an example of an adaptive coping strategy, which is a cognitive or behavioral effort to manage stressful conditions or associated emotional distress.
Meditation can help reduce tension, enhance relaxation, and promote well-being.
Choice A is wrong because the client consumes 3 glasses of wine after a stressful day at work. This is an example of an avoidance coping strategy, which is an attempt to reduce stress by avoiding dealing directly with the problem.
Alcohol consumption can have negative effects on physical and mental health, and does not address the source of stress.
Choice C is wrong because the client keeps all unresolved conflict to themselves. This is an example of an emotion-focused coping strategy, which is an attempt to regulate the emotional distress caused by a stressor.
However, this strategy can be maladaptive if it involves suppressing or denying emotions, which can lead to increased psychological distress and poor interpersonal relationships.
Choice D is wrong because the client consumes a half gallon of ice cream after an argument with a coworker. This is another example of an avoidance coping strategy, which is an attempt to reduce stress by avoiding dealing directly with the problem.
Ice cream consumption can have negative effects on physical health, such as obesity and diabetes, and does not address the source of stress.
Correct Answer is ["A","B","C","D"]
Explanation
The correct answers are Choices A, B, C, and D.Choice A rationale:Inspection of lips and mucous membranes is a vital assessment technique for hydration status. Dryness or cracking of the lips and mucous membranes can indicate dehydration, as these areas are often affected by fluid loss. Observing these features helps healthcare providers assess the client's hydration level effectively.Choice B rationale:Pinching the skin on the back of the hand tests skin turgor, which is a reliable indicator of hydration status. If the skin does not return to its normal position quickly after being pinched, it suggests decreased skin elasticity due to dehydration. This method provides a quick visual and tactile assessment of fluid levels in the body.Choice C rationale:Measuring pulse and blood pressure is essential in evaluating hydration status. Changes in blood pressure (especially orthostatic hypotension) and pulse rate can indicate fluid volume changes in the body. An increased heart rate may suggest dehydration, while low blood pressure can indicate significant fluid loss.Choice D rationale:Obtaining the client's daily weight is a crucial method for monitoring hydration status. Weight fluctuations can provide insight into fluid retention or loss over time. A sudden decrease in weight may indicate dehydration, while an increase could suggest fluid overload or retention issues.Choice E rationale:Palpating scalp and hair distribution is not a common or effective method for assessing hydration status. While scalp condition may reflect overall health, it does not provide direct information about hydration levels compared to other methods listed.
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